A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
Ignoring the urge to defecate
Increased fiber in the diet
Excessive laxative use
Increased activity
Correct Answer : A,C
Choice A reason: Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
Choice B reason: Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
Choice C reason: Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
Choice D reason: Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
Correct Answer is B
Explanation
Choice A reason: The pulse oximeter might not be accurate during times of excessive movement is a correct statement, as movement can interfere with the detection of the pulse and the oxygen saturation. The parents should try to keep the infant still and calm while using the pulse oximeter.
Choice B reason: We will notify the doctor if the pulse oximeter consistently reads 100% is an incorrect statement, as it indicates a misunderstanding of the normal range of oxygen saturation. The parents should not be alarmed if the pulse oximeter reads 100%, as it means that the infant's blood is fully saturated with oxygen. The normal range of oxygen saturation for infants is 95% to 100%.
Choice C reason: The probe of the pulse oximeter can be applied to a finger or a toe is a correct statement, as these are suitable sites for measuring the oxygen saturation in infants. The parents should make sure that the probe fits snugly and securely on the infant's finger or toe.
Choice D reason: We will rotate the probe of the pulse oximeter every 24 hours is a correct statement, as it helps to prevent skin irritation, pressure ulcers, or infection from prolonged contact with the probe. The parents should also check the infant's skin regularly for any signs of redness, swelling, or pain.
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