A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury.
Which of the following actions should the nurse include in the plan of care?
Encourage a maximum fluid intake of 1,500 mL per day.
Increase the amount of refined grains in the client’s diet.
Provide the client with a cold drink prior to defecation.
Administer a cathartic suppository 30 min prior to scheduled defecation times.
The Correct Answer is D
The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A
bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.
Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.
Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.
Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.
Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.
Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.
Correct Answer is A
Explanation
The correct answer is choice A. A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.
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