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A nurse caring for a patient who reports frequent constipation learns the patient uses phosphate and sodium citrate enemas several times weekly. What education would the nurse provide?
- A. Avoid consuming fiber or roughage in the diet.
- B. Sedentary activities will be helpful.
- C. These enemas should be avoided with kidney failure.
- D. Restrict your fluids to 1,000 mL daily.
Correct Answer: C
Rationale: Phosphate and sodium citrate enemas (C) are contraindicated in kidney failure due to risk of hyperphosphatemia. Fiber (A) promotes regularity, activity (B) aids peristalsis, and fluid restriction (D) worsens constipation.
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A nurse is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
- A. Saline osmotic laxative
- B. Bulk-forming laxative
- C. Methylcellulose
- D. Stool softener
Correct Answer: A
Rationale: Saline osmotic laxatives (A) can cause fluid/electrolyte imbalances in older adults, especially with kidney or cardiac issues, and should be avoided. Bulk-forming (B, C) and stool softeners (D) are safer options.
A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure, the patient tells the nurse they are feeling dizzy and nauseated and then vomits. What should be the nurse's next action?
- A. Reassuring the patient that this is a normal reaction to the procedure
- B. Stopping the procedure, preparing to administer CPR, and notifying the primary care provider
- C. Stopping the procedure, assessing vital signs, and notifying the health care provider
- D. Pausing the procedure, waiting 5 minutes, and then resuming the procedure
Correct Answer: C
Rationale: Dizziness, nausea, and vomiting suggest vagal stimulation. Stopping the procedure, assessing vital signs, and notifying the provider (C) is appropriate. Reassuring (A) ignores the risk, CPR (B) is premature, and resuming after 5 minutes (D) is unsafe without assessment.
A nurse in a long-term care facility is assessing a group of patients. In which patients would the nurse anticipate increased risk for developing diarrhea? Select all that apply.
- A. Patient taking opioids for pain
- B. Patient taking metformin for type 2 diabetes
- C. Patient taking diuretics
- D. Patient who developed dehydration
- E. Patient taking amoxicillin clavulanate for infection
- F. Patient taking magnesium-containing antacids
Correct Answer: B,E,F
Rationale: Diarrhea is a side effect of metformin (B), amoxicillin clavulanate (E), and magnesium-containing antacids (F). Opioids (A), diuretics (C), and dehydration (D) are more likely to cause constipation.
A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
- A. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
- B. Percussing all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen
- C. Lightly palpating over the abdominal quadrants; first checking for any areas of pain or discomfort
- D. Deeply palpating over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses
Correct Answer: A
Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation (A) follows inspection because palpation may alter bowel sounds. Percussion (B) and palpation (C, D) come later to avoid disturbing peristalsis.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test?
- A. Having the patient consume a low-fiber diet several days before the test
- B. Having the patient take bisacodyl and ingest a gallon oral polyethylene glycol solution (PEG)
- C. Preparing the patient for the use of general anesthesia during the test
- D. Explaining that barium contrast mixture will be given to drink before the test
Correct Answer: A
Rationale: A low-fiber diet several days before a colonoscopy (A) reduces residue in the colon. PEG is used, but bisacodyl (B) isn't standard for all preps. Conscious sedation, not general anesthesia (C), is typical, and barium (D) is for other GI tests.