A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.
The nurse is preparing to discharge the patient.
What is the most important instruction for the nurse to include in the discharge teaching plan?

.Administer a stool softener: This could be a good option to consider, as the client has not had a bowel movement since the surgery. However, the nurse should first consult with the healthcare provider before administering any new medications.

B.Ask the client about their normal bowel routine: This is a good action to take. Understanding the client’s normal bowel routine can provide valuable context for the current situation.

C.Hold the client’s next meal: This may not be necessary at this point. The client’s regular diet has been ordered by the provider, and there’s no indication of nausea, vomiting, or other symptoms that would necessitate holding meals.

D.Perform a digital rectal exam: This could be considered if there’s a concern about impaction or other complications. However, this should only be done after consulting with the healthcare provider.

E.Discontinue morphine: This is not advisable based on the information provided. The client is reporting uncontrolled pain, and morphine has been ordered by the provider for pain management. Any changes to pain medication should be discussed with the healthcare provider.

Choice A rationale

Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.

Choice B rationale

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.

Choice C rationale

Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.

Choice D rationale

Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.