A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Allow the perineal area to air dry after each stool.

Administer a soap-suds enema to cleanse the colon.

Provide the client with a high fiber diet.

Apply a zinc-oxide barrier to the perineal area after each stool.

Answer and Explanation

The Correct Answer is D

A. Allow the perineal area to air dry after each stool. While drying is important, leaving the skin unprotected can lead to skin breakdown and irritation from continued exposure to stool.

B. Administer a soap-suds enema to cleanse the colon. Soap-suds enemas are contraindicated in diarrhea because they can cause further irritation and electrolyte imbalances.

C. Provide the client with a high-fiber diet. A high-fiber diet is recommended for constipation, not diarrhea, as fiber can increase stool frequency.

D. Apply a zinc-oxide barrier to the perineal area after each stool. Zinc-oxide protects the skin from moisture and irritation, helping prevent dermatitis and skin breakdown.

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Correct Answer is A

Explanation

A. Paralytic ileus. A postoperative complication in which the intestines stop moving due to anesthesia or surgical trauma. Absence of bowel sounds, abdominal distention, and no flatus are key signs.

B. Incisional infection. An incisional infection would present with redness, warmth, drainage, and fever, but not absence of bowel sounds.

C. Fecal impaction. Fecal impaction causes stool retention, and the client might still pass small amounts of liquid stool, whereas paralytic ileus presents with no bowel movement at all.

D. Health care-associated Clostridium difficile. C. difficile infection presents with frequent watery diarrhea, not absent bowel sounds.

A. Absent B. Blowing sound due to restriction. C. A continuous medium pitched sound. D. High pitched, tinkling, rushing or growling.

Correct Answer is D

Explanation

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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A nurse is contributing to the plan of care for a client who has frequent diarrheal stools. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Correct Answer is A

Explanation

When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Correct Answer is D

Explanation

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