Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Evaluate the client's ability to recognize the urge to defecate.

Determine the frequency and consistency of bowel movements.

Observe the skin integrity of the client's rectal and sacral areas.

Assess the client's strength in moving and turning in the bed.

Answer and Explanation

The Correct Answer is B

A) Evaluate the client's ability to recognize the urge to defecate: Assessing the client's ability to recognize the urge to defecate is important for promoting independence in toileting. However, this assessment may not directly indicate the need for administering a laxative. It is more relevant for clients who are able to ambulate or have control over their bowel movements.

B) Determine the frequency and consistency of bowel movements: Assessing the frequency and consistency of bowel movements provides valuable information about the client's bowel function and helps determine the need for a laxative. It allows the nurse to establish a baseline and evaluate the effectiveness of interventions. Understanding the client's typical bowel pattern is crucial before administering a laxative to avoid overmedication or potential complications such as diarrhea or fecal impaction.

C) Observe the skin integrity of the client's rectal and sacral areas: Assessing skin integrity in the rectal and sacral areas is crucial for preventing pressure ulcers, especially in bedfast clients. However, it is not directly related to the need for administering a laxative.

D) Assess the client's strength in moving and turning in the bed: While assessing the client's strength and mobility is important for overall care and prevention of complications related to immobility, it may not be directly related to the need for administering a laxative. This assessment is more relevant for preventing complications such as pressure ulcers and maintaining musculoskeletal function.

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Correct Answer is C

Explanation

A) Taking the medication one hour after meals and other medications may help prevent interference with the absorption of nutrients or other medications. However, it is not a specific instruction related to the administration of bulk-forming laxatives.

B) Remaining upright for thirty minutes following drug administration is a common instruction for medications that may cause esophageal irritation or reflux. However, it is not typically necessary for bulk-forming laxatives, which work primarily in the colon rather than the esophagus or stomach.

C) Following medication administration with an additional glass of water is the correct instruction for self-administration of bulk-forming laxatives. These laxatives absorb water in the intestines, which helps to soften the stool and promote bowel movements. Adequate hydration is essential to prevent the bulk-forming laxative from causing intestinal obstruction.

D) Avoiding the intake of dairy products while using the medication is not a specific instruction related to the administration of bulk-forming laxatives. Bulk-forming laxatives are generally well-tolerated and do not interact with dairy products. However, increasing fluid intake, particularly water, is essential to prevent constipation and ensure the effectiveness of the medication.

A. Take with a glass of milk. B. Use a straw to ingest. C. Swallow undiluted. D. Mix with an antacid.

Correct Answer is B

Explanation

A) Taking ferrous sulfate elixir with a glass of milk is not recommended because milk can interfere with the absorption of iron. Iron absorption is enhanced in an acidic environment, and milk's ca’cium content can inhibit this process.

B) Using a straw to ingest the ferrous sulfate elixir is advisable because it can help minimize contact between the medication and the teeth, reducing the risk of staining. Iron supplements can cause discoloration of the teeth, and using a straw directs the liquid towards the back of the mouth, bypassing the teeth.

C) Swallowing ferrous sulfate elixir undiluted is the usual method of administration; however, doing so may increase the risk of staining the teeth due to direct contact with the oral mucosa and teeth. It is important to follow the healthcare provider's in’tructions regarding dosage and administration.

D) Mixing ferrous sulfate elixir with an antacid is generally not recommended unless specifically directed by the healthcare provider. Antacids containing calcium or magnesium can bind to iron, forming complexes that are poorly absorbed in the gastrointestinal tract, thereby reducing the effectiveness of iron supplementation.

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Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include when teaching a client about self-administration of a bulk-forming laxative?

Correct Answer is C

Explanation

Ferrous sulfate elixir is prescribed for a client with iron deficiency anemia. Which instruction should the nurse provide this client about taking the liquid medication?

Correct Answer is B

Explanation

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