Which word should the nurse use when describing to a client how a soapsuds enema affects the intestine?
Lubricating
Irritating
Dilating
Softening
The Correct Answer is B
A. Lubricating: A lubricating enema typically refers to an enema solution that contains a lubricant, such as mineral oil, to help soften feces and facilitate their passage from the rectum. Lubricating enemas are used to alleviate constipation by easing the passage of stool. However, soapsuds enemas do not primarily function as lubricating enemas.
B. Irritating: This is the correct option. Soapsuds enemas contain soap or detergent mixed with water, and their primary action is to irritate the intestinal mucosa. The irritation stimulates peristalsis, which promotes bowel evacuation. Soapsuds enemas are often used to relieve constipation by inducing bowel movements through irritation of the intestinal lining.
C. Dilating: Dilating refers to widening or enlarging a structure. While enemas, including soapsuds enemas, may contribute to the relaxation and dilation of the rectum and lower bowel, the primary action of a soapsuds enema is to stimulate bowel evacuation through irritation rather than dilation.
D. Softening: Softening enemas typically involve the introduction of a solution, such as a mineral oil-based solution, to soften feces and facilitate their passage from the rectum. While softening enemas help alleviate constipation by softening stool consistency, soapsuds enemas do not primarily function as softening enemas. Their main action is to stimulate bowel evacuation through irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Quickly resuming the client's normal food intake: This is not recommended, as the client's gastrointestinal system needs time to recover from food poisoning. Resuming normal food intake too quickly may exacerbate symptoms or prolong recovery. It's essential to give the gastrointestinal system time to heal and gradually reintroduce foods as tolerated.
Answer: B. Requesting a prescription for an antidiarrheal drug from the provider.
C. Encouraging easily digestible foods when the diarrhea stops.
Rationale:
When caring for a client with profuse diarrhea from food poisoning, the nurse's interventions should focus on managing symptoms, preventing dehydration, and promoting recovery. Options B and C are appropriate nursing interventions for this scenario:
B. Requesting a prescription for an antidiarrheal drug from the provider: Antidiarrheal medications such as loperamide (Imodium) may be prescribed to help control diarrhea and reduce fluid loss. These medications work by slowing down bowel motility and can provide symptomatic relief, particularly for clients with profuse diarrhea from food poisoning. However, the use of antidiarrheal drugs should be guided by a healthcare provider's prescription to ensure appropriate dosing and monitoring, especially considering individual client factors and potential contraindications.
C. Encouraging easily digestible foods when the diarrhea stops: This is the correct option. Once the diarrhea subsides, it is appropriate to encourage the client to gradually reintroduce easily digestible foods. These foods are gentle on the digestive system and help prevent further irritation or upset. Examples of easily digestible foods include bananas, rice, applesauce, toast (BRAT diet), boiled potatoes, boiled chicken, and clear broths.
D. Limiting the client's fluid intake to about 1000 mL/day: Fluid intake should be encouraged rather than limited, especially in cases of profuse diarrhea. Diarrhea can lead to significant fluid loss and dehydration, so it's crucial to ensure adequate hydration. The client should be encouraged to drink clear fluids such as water, electrolyte solutions, and herbal teas to replace lost fluids and electrolytes.
Correct Answer is ["B","C","D"]
Explanation
A. Administering diuretics as ordered: This option is not appropriate for dehydration management. Diuretics are medications that increase urine output and are typically used to treat fluid overload rather than dehydration. Administering diuretics to a dehydrated client could exacerbate fluid loss and worsen the condition.
B. Providing good skin and mouth care: This is a suitable intervention for managing dehydration. Dehydration can lead to dry skin and mucous membranes. Providing good skin care, including moisturizing, can help prevent skin breakdown. Additionally, ensuring adequate oral hygiene and providing moist mouth swabs can alleviate discomfort associated with dry mouth.
C. Monitoring intake and output: This is an essential nursing intervention for managing dehydration. Monitoring the client's fluid intake and output allows the nurse to assess the balance between fluid intake and loss. Decreased urine output is a common sign of dehydration, while monitoring intake helps ensure the client is receiving adequate fluids.
D. Obtaining daily weights: This is an appropriate nursing intervention for managing dehydration. Daily weights can help assess changes in fluid balance. A sudden increase in weight may indicate fluid retention, while a decrease may indicate ongoing fluid loss, both of which are important to monitor in dehydration.
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