A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Take an over-the-counter laxative every morning.

Drink six to eight large glasses of water daily.

Try using over-the-counter enemas when needed.

Walk around the block or further every day.

Answer and Explanation

The Correct Answer is B

A.   While over-the-counter laxatives can be effective for relieving constipation, they are typically recommended for short-term use or when dietary and lifestyle changes have not resolved the issue. Regular or frequent use of laxatives can lead to dependence and potentially worsen constipation over time.
B.   Increasing water intake is a highly effective way to address constipation. Adequate hydration helps soften the stool, making it easier to pass. Drinking six to eight large glasses of water daily is a good strategy to promote regular bowel movements and prevent constipation.
C.   Over-the-counter enemas can provide immediate relief from constipation but should not be used frequently. Enemas are more invasive and can cause discomfort or lead to dependency if used too often. They are typically recommended for occasional use rather than as a first-line solution for chronic constipation.
D.   Regular physical activity, such as walking, can help stimulate bowel movements and alleviate constipation. Exercise promotes gut motility and can be an effective part of a comprehensive approach to managing constipation.

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Correct Answer is A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

A. Tell the client to use larger bags that expand with gas. B. Teach the client how to burp the bag to relieve the gas. C. Ensure that the pin holes are made at the top of the bag. D. Inform the client about bags that have gas release valves.

Correct Answer is D

Explanation

A. Using larger bags might help accommodate the gas more comfortably and reduce the need for making pinholes. However, this solution does not address the immediate issue of gas accumulation and may not be practical for all clients.
B. "Burping" the bag is a recognized technique for managing gas in colostomy bags. It involves opening the end of the bag slightly to release gas, which helps to prevent the bag from ballooning and causing discomfort. This method is effective and safe, as it is specifically designed to manage gas without compromising the integrity of the bag.
C. Making pinholes in the colostomy bag is not a recommended practice. Pinholes can lead to leakage and increase the risk of skin irritation or infection. While ensuring the pinholes are at the top might reduce some complications, it does not solve the fundamental issue and poses a risk to the client's health and hygiene.
D. Colostomy bags equipped with built-in gas release valves are designed specifically to manage gas accumulation safely and effectively. Informing the client about these specialized bags provides a practical solution to the problem of gas buildup and avoids the risks associated with making pinholes.

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A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is A

Explanation

A client with a colostomy tells the nurse about making small pin holes in the drainage bag to help relieve the gas that collects. Which action should the nurse implement?

Correct Answer is D

Explanation

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