Study sets, textbooks, questions
Upgrade to remove ads
HESI 5 Constipation
Get Quizlet's official HESI A2 - 1 term, 1 practice question, 1 full practice test
Terms in this set (29)
1) Janelle Case, a 65-year-old female client on the medical surgical unit, has an abdominal hysterectomy. Three days later, she is reporting abdominal bloating, pain, and nausea. Janelle is reluctant to eat or drink anything, stating, "The smell of food makes me nauseated." She informs the nurse that she feels constipated and has not passed a bowel movement since prior to surgery. The nurse observes that Janelle's abdomen is firm and distended. The nurse performs an abdominal assessment. Which sequence should the nurse perform the abdominal assessment?
Inspection, auscultation, percussion, palpation (Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.)
2)Which assessment is most important for the nurse to perform?
Auscultate bowel sounds (The subjective data reported by Janelle (bloated and nauseated) and objective data gathered by the nurse (abdomen firm and distended) suggest that Janelle may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds.)
3)Which is the most important action for the nurse to perform when assessing bowel sounds?
Begin auscultation in the right lower quadrant. (The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants.)
4)The nurse auscultates for Janelle's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document?
Hypoactive bowel sounds (Normally, bowel sounds are heard 5 to 35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive. Although diminished bowel sounds reflect reduced peristalsis, this is not an assessment finding, rather this would be considered a probable cause).
5)While the nurse is completing the assessment, Janelle begins to cry and laments, "I just knew something would go wrong."
"Tell me what is making you feel so upset." (This open-ended statement encourages the client to express further concerns and fears.)
6)Janelle tells the nurse, "I hate hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong."
"It sounds as if you have had another experience that did not go well." (The nurse's response validates Janelle's feelings, which will encourage Janelle to verbalize further.)
7)Janelle responds, "I did everything my HCP told me to do. The surgery must have caused this. They must have made a mistake." Which explanation by the nurse is accurate?
Explain to the client the multiple factors that can decrease peristalsis postoperatively, 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.)
8)The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation. Which postoperative medication is most likely to contribute to constipation?
Morphine sulfate, an opioid analgesic (The most common adverse effect of opioid analgesics is constipation.)
9)What impact does this fluid intake have on Janelle's bowel patterns?
This inadequate fluid intake has contributed to her constipation. (An adult needs 1,400 to 2,000 mL of fluid daily to prevent hardening of the stool.)
10)What other questions should the nurse ask Janelle?
"How often do you get out of bed and walk?" (Immobility is a major risk factor for constipation.)
11)Further assessments and testing are ordered to assist in the diagnosis of constipation. An upper GI series (Barium swallow) is ordered. Janelle appears nervous, and asks the nurse to explain this procedure.
A barium liquid is swallowed and a series of x-rays are taken (An upper GI series involves swallowing a barium liquid, followed by a series of x-rays taken of the esophagus, stomach and duodenum.)
12)The nurse determines that Janelle's inadequate fluid intake, decreased mobility, and opioid use are significant factors in the development of her constipation. Which nursing diagnosis should the nurse include in Janelle's plan of care?
Constipation related to surgery and anesthesia (This diagnostic statement uses the correct format and identifies both the problem and the etiology.)
13)The nurse explains to Janelle that her HCP has prescribed two medications: a one-time dose of bisacodyl rectal suppository and docusate sodium 100 mg PO daily. The nurse explains that the bisacodyl suppository will have a laxative effect. How will the nurse explain to Janelle the action of the laxative?
Soften the stool, distend the rectum to expel the stool." (Laxatives soften the stool and stimulate the rectal mucosa to produce soft or liquid stool.)
14)The nurse administers the first dose of docusate sodium. This medication primarily alters which aspect of a client's bowel movement?
Consistency. (Docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.) Frequency of bowel movements may be indirectly effected, and amount of stool may be indirectly effected, but these are not the primary effects.
15)Before administering the rectal suppository, how should the client be positioned?
Sim's Position (The client should be in Sim's position, on the left side, with the knee flexed.)
16)When administering the rectal suppository, the nurse asks Janelle to take several slow, deep breaths. What is the rationale for this instruction?
Relax the anal sphincter and reduce discomfort (Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.)
17)After administering the rectal suppository, it is most important for the nurse to document which information?
0900. One bisacodyl suppository administered per rectum for constipation, as prescribed. (This documentation correctly identifies the medication, the dose, the time, and the route of administration, as well as the reason for administering the medication.)
18)Which statement provides the best documentation describing the outcome from the suppository administration?
1100. Client produced six, ¼ inch, hard pellets of brown stool following suppository administration (This documentation provides the most specific objective data related to the effectiveness of the suppository.)
19)The next day, Janelle has still not expelled additional feces. To determine the presence of a fecal impaction, the nurse prepares Janelle for which prescribed procedure?
A) Radiographic examination (Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction.) and B) Digital rectal examination (Digital rectal examination is the procedure performed to assess for the presence of a fecal impaction).
20)The UAP obtains sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy. Which action is the most important for the nurse to implement?
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 a client at risk. The UAP can be assigned to assist the nurse with client positioning. Having the UAP assist in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use nonsterile exam gloves, which are less costly than sterile gloves, and lubricant for this procedure.)
21)While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?
Decreased pulse rate and decreased blood pressure (Vagal nerve stimulation can cause a reflex slowing of the heart rate.)
22) The nurse notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for enema administration. What action should the nurse implement?
Administer the enema as prescribed and obtain the HCP's signature the next day (A verbal prescription is legally permissible. The nurse should, however, take measures to ensure client safety because verbal prescriptions can be a source of error. The nurse should read back the complete prescription and have the verbal prescription signed within 24 hours. Some healthcare agencies do not allow verbal prescriptions, so it is important for the nurse to adhere to agency policy.)
23)When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the HCP, who sounds angry and shouts, "Are you questioning my prescription?" Which approach by the nurse is the best response to the angry HCP?
"I want to ensure that I transcribe this prescription correctly to avoid error." (This assertive response teaches the HCP the purpose of repeating back verbal prescriptions.)
24)The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Janelle begins to experience abdominal cramping. What actions should the nurse take to relieve the abdominal cramping?
A) Slow the rate of the infusion (Slowing the rate of the enema infusion and reassessing the client ,should reduce or stop the client's abdominal cramping.) and if slowing doesn't stop the cramping may then B) Roll the clamp to stop the 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.)
25) Janelle has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Janelle, the nurse receives report from the UAP that another client is vomiting. The nurse tells Janelle she will return as soon as she deals with the other client's problem. What task can the nurse delegate to the UAP?
A) Assist the client with a bed bath and hygiene if required (Hygiene and comfort care are both within the UAP's scope of practice.) and B) Assist the client who vomited with mouth care after the RN administers an antiemetic (Hygiene and comfort care are both within the UAP's scope of practice).
26)How will the nurse accurately explain the amount of fluid to Janelle using household measurements, given Janelle received a total volume of 725 mL? The nurse assesses the client who is vomiting and acts to alleviate this problem. The nurse returns to Janelle's room. Janelle is interested in the amount of fluid administered via the enema but does not understand milliliters. Janelle received a total volume of 725 mL.
3 cups (The conversion factors needed are as follows: 30 mL = 1 ounce, and 1 cup = 8 ounces. 725 mL/30 = 24 ounces/8 = 3 cups.)
27)The nurse encourages Janelle to increase her daily oral fluid intake to 2 liters of fluid for the next few days. The nurse advises Janelle to drink a minimum of how many 8-ounce cups of fluid daily?
Eight to nine cups (One 8-ounce cup contains 240 mL (8 x 30 mL/ounce) Two liters = 2,000 mL 2,000 mL/240 mL = 8.33 cups/day)
28)The remainder of Janelle's surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Janelle eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity.Which type of diet should the nurse recommend?
High fiber (High fiber foods accelerate the passage of food through the intestines, which is important for bowel regularity).
29)The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by Janelle indicates that she understands teaching about dietary measures to promote bowel regularity?
Orange juice and oatmeal with raisins (Whole grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity).
Other sets by this creator
HESI 4 Urinary Patterns
Vital Signs Ch 10
HESI 1 Integumentary Assessment
Other Quizlet sets
USS Shoup Basic DC
Week 1 Mastery for Human Origins
Chapter 8: Media and Technology