A. Auscultation, Inspection, Percussion, Palpation
B. Inspection, Palpation, Auscultation, Percussion
C. Inspection, Auscultation, Percussion, Palpation
D. Auscultation, Percussion, Inspection, Palpation
Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.
A. Auscultate bowel sounds.
B. Measure abdominal girth.
C. Observe incisional staples.
D. Measure bloop pressure
Based on subjective data by Joan (bloated and nauseated) and objective data by the nurse (abdomen firm and distended), the nurse’s first concern is that Joan may have decreased peristalsis.
A. Ask the client when she had her last bowel movement.
B. Listen for up to 5 minutes when auscultating the bowl sounds.
C. Perform a rectal exam.
D. Place client in knee-chest position to expel excess gas prior to auscultation.
The nurse must listen for up to 5 minutes before determining what type of bowl sounds are present.
A. Hypoactive bowel sounds.
B. Normal bowel sounds.
C. Paralytic ileus.
D. Reduced peristalsis.
Normally, bowel sounds are heard 5-35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive.
A. “This is a minor problem. We’ll have you better very soon.”
B. “You have to expect that problems will occur after surgery.”
C. “Tell me what is making you feel so upset.”
D. “Why are you letting this upset you?”
This open-ended statement encourages the client to express further concerns and fears.
A. “All the nurses are very busy here, and they are doing the best job they can.”
B. “You should write down your questions so you can get some answers.”
C. “I will be happy to tell you everything that’s happening, so nothing else will go wrong.”
D. “It sounds as if you have had another experience that did not go well.”
The nurse’s response validates Joan’s feelings, which will encourage Joan to verbalize further.
A. Refer to the client to the surgeon to answer any questions about the surgical outcome.
B. Advise the client that an incarcerated hernia is repaired to improve peristalsis so an error must have occurred during the surgery.
C. Offer the client emotional support as she copes with this adverse outcome of surgery.
D. Explain to the client the multiple factors that can decrease peristalsis postoperatlively, even when the desired surgical outcome is achieved.
Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis.
A. Morphine sulfate, an opioid analgesic.
B. Ibuprofen (Advil), a non-opioid analgesic.
C. Promethazine (Phenergan), an antiemetic.
D. Cefazolin (Ancef), an antibiotic.
The most common adverse effect of opioid analgesics is constipation.
A. This inadequate fluid intake has contributed to her constipation.
B. This sufficient amt. of fluid intake has not affected her bowel patterns.
C. This large amount of fluid intake has helped keep her feces soft.
D. Intravenous fluids have little or no impact on intestinal contents and bowel patterns.
An adult needs 1,400 to 2,000 ml of fluid daily to prevent hardening of the stool.
A. “How often do you get out of bed and walk?”
B. “Are you using your incentive spirometer regularly?”
C. “When was your abdominal dressing last changed?”
D. “Are you wearing your compression devices while in bed?”
Immobility is a major risk factor for constipation.
A. Plan the desired outcome and goal of care.
B. Determine which factor is causing the problem.
C. Consider possible nursing actions to resolve the problem.
D. Consult with the healthcare provider regarding the risk factors involved.
The cause of the problem should be determined since this is a component of the diagnostic statement.
A. Risk for constipation and lack of fluid intake.
B. Inadequate fluid intake, resulting in constipation.
C. Constipation related to surgery and anesthesia.
D. Constipation as manifested by decreased bowel sounds.
This diagnostic statement uses the correct format and identifies both the problem and the etiology.
A. “The stool will be broken up so that it will be small enough to be expelled from your rectum.”
B. “Movement of the intestine will push the bowl contents out so you will have a bowl movement.”
C. “The hard stool will be softened so you will not have to strain to have a bowl movement.”
D. “You may experience abdominal cramping and may even have some diarrhea as the result of this medication.”
Laxatives stimulate peristalsis so that the bowl contents can then be expelled.
Surfak is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.
A. Ask about the client’s normal bowel patterns.
B. Monitor the client’s blood pressure and pulse.
C. Determine if the client has any hemorrhoids.
D. Observe for the presence of rectal bleeding.
The administration of a rectal suppository is generally contraindicated in the presence of rectal bleeding, so this assessment is the most important.
A. Distract Joan from the suppository insertion.
B. Relax the anal sphincter and reduce discomfort.
C. Improve intestinal peristalsis and motility.
D. Reduce spasms from hemorrhoids.
Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.
A. 0900. Lubricant used when one glycerin suppository inserted.
B. 0900. One suppository inserted because of constipation.
C. 0900. One glycerin suppository administered per rectum for constipation, as prescribed.
D. 0900. One laxative (glycerin) administered for constipation.
This documentation correctly ID’s the med, the dose, the time, and the route of administration, as well as teh reason for administering the med.
A. Client reports that the suppository was not helpful in relieving constipation.
B. Client produced six 1/4 inch hard pellets of brown stool following suppository administration.
C. Client will need additional treatment to resolve problem of constipation.
D. Dulcolax suppository administration produced only a small amount of feces.
This documentation provided the most specific objective data related to the effectiveness of the suppository.
A. Insertion of a rectal tube.
B. Enema administration.
C. Digital rectal examination.
Digital rectal exam is the procedure performed to assess for the presence of a fecal impaction.
A. Tell the UAP to perform the procedure using the lubricant, but advise her that the use of sterile gloves is not necessary.
B. Perform the procedure using the supplies obtained by the UAP.
C. Commend the UAP for her willingness to help and ask her to leave the supplies for the healthcare provider, who must perform the procedure.
D. Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed.
This task should not be delegated to the UAP because it is an invasive procedure that places the client at risk. The UAP can be assigned to assist the nurse with client positioning. Assisting in this manner provides an opportunity for the nurse to teach the UAP that this is not sterile procedure. The nurse should use nonsterile exam gloves, which are less costly than sterile gloves, and lubricant for this procedure.
A. Increased blood pressure.
B. Increased temperature.
C. Decreased respirations.
D. Decreased pulse rate.
Vagal nerve stimulation can cause a reflex slowing of the heart rate.
A. Wait to administer the enema until the healthcare provider is able to sign the prescription in person.
B. Administer the enema as prescribed and obtain the healthcare provider’s signature the next day.
C. Explain to the healthcare provider that verbal prescriptions are not legally defensible, and a written prescription is needed.
D. Ask the charge nurse to assist with preparing a variance report to explain the use of verbal prescription.
A verbal Rx is legally permissible. The nurse should, however, take measures to ensure client safety b/c verbal Rx’s can be a source of error. The nurse should read back the complete Rx and have the verbal Rx signed w/i 24hrs. Some healthcare agencies do not allow verbal Rx’s, so it is important for the nurse to adhere to agency policy.
A. “Make sure you sign this verbal Rx w/i 24 hours.”
B. “I want to ensure that I transcribe this Rx correctly to avoid error.”
C. “You should be glad I want to ensure the accuracy of this Rx”
D. “I have the responsibility to question any Rx’s I do not feel are correct.”
This assertive response teaches the healthcare provider the purpose of repeating back verbal Rx’s.
A. Raise the head of the bed.
B. Lower the enema bag.
C. Assess the client’s vital signs.
D. stop the enema and assist Joan to the bathroom.
E. Roll the clamp to stop enema until cramping subsides.
Lowering the enema bag will slow or stop the flow of fluid, which should reduce or stop the client’s abdominal cramping.
E. Roll the clamp to stop enema until cramping subsides.
This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.
A. Decide if Joan needs another enema.
B. Give the vomiting client an antiemetic.
C. Teach Joan how to self-administer the enema.
D. Assist the client who vomited with mouth care and bathing after the nurse administers the antiemetic.
Hygiene and comfort care are both w/i the UAP’s scope of practice.
A. 3 cups.
B. 6 cups.
C. 1 quart.
D. 1/2 gallon.
The conversion factors needed are: 30ml=1oz, and 1 cup=8oz. 725 ml/30=24 oz/8 =3 cups.
One 8-oz cup contains 240 ml (8×30 ml/oz). Two liters=2000ml. 2000ml/240ml=8.33 cups/day.
A. Fresh fruit salad w/ apple and banana slices.
B. Canned pears w/ low-fat cottage cheese.
C. Tuna salad w/ eggs and mayonnaise.
D. Pasta salad w/pepperoni and ham.
Fresh fruits are a good source of fiber, which is important for bowel regularity.
A. Toasted bagel w/jam, and skim milk.
B. Pancakes w/ maple syrup, and coffee.
C. Bacon & eggs, & herbal tea.
D. Oatmeal w/ raisins and OJ
Whole-grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.
Joan expresses her thanks to the nurse and states she feels confident in her ability to manage her diet, fluid intake, and activity when she is discharged to ensure regular bowel patterns.