A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?
Insert a rectal tube at specified intervals.
Assist to a bedside commode 30 minutes after meals.
Encourage the use of incontinence briefs.
Administer a glycerin suppository 15 minutes after meals.
The Correct Answer is B
Choice A rationale
Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.
Choice B rationale
Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.
Choice C rationale
Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.
Choice D rationale
Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.
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Correct Answer is B
Explanation
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.
Correct Answer is D
Explanation
Choice A rationale
Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.
Choice B rationale
Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.
Choice C rationale
Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.
Choice D rationale
Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.