A nurse is caring for a client who has bowel incontinence and is placed on a bowel training program. Which of the following actions should the nurse take?

Teach the client to strain when having a bowel movement.

Encourage the client to drink a hot beverage just before she needs to defecate.

Allow the client to sit on the toilet for 1 hr to defecate.

Limit exercise for the client while she is on the bowel training program.

Answer and Explanation

The Correct Answer is B

A. Teach the client to strain when having a bowel movement. Straining can cause harm and is not recommended.
B. Encourage the client to drink a hot beverage just before she needs to defecate. A hot beverage can stimulate bowel movements and help establish a routine.
C. Allow the client to sit on the toilet for 1 hr to defecate. Prolonged sitting can cause discomfort and is not practical.
D. Limit exercise for the client while she is on the bowel training program. Exercise is beneficial for overall health and can promote regular bowel movements.

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Correct Answer is D

Explanation

A. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis and varicella, not bacterial meningitis.
B. Protective environment precautions are used for clients with severely compromised immune systems, not for preventing the spread of bacterial meningitis.
C. Contact: Contact precautions are used for infections spread by direct contact with the patient or their environment, such as MRSA or C. difficile, not bacterial meningitis.
D. Droplet: This is correct. Droplet precautions are required for bacterial meningitis as it spreads through large respiratory droplets.

A. Flush the port with heparin prior to administering the medication. B. Inject the medication into the port closest to the client. C. Pinch the tubing below the injection port prior to administration. D. Administer the medication over 10 seconds.

Correct Answer is B

Explanation

A. Flush the port with heparin prior to administering the medication. Heparin is not typically used to flush the port before administering IV medications; saline is generally used for flushing.
B. Inject the medication into the port closest to the client. This ensures the medication is delivered quickly and effectively, minimizing dilution and maximizing its effect.
C. Pinch the tubing below the injection port prior to administration. Pinching the tubing can help ensure the medication goes into the client quickly but should be done only if specified by protocol.
D. Administer the medication over 10 seconds. Fentanyl should be administered slowly over 1-2 minutes to prevent rapid administration-related side effects like hypotension or respiratory depression.

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