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

helps train the body to respond to natural urges.

B. Immediately before meals. Although eating stimulates peristalsis, this is not the most effective approach because the client may not be ready to defecate at that time.

C. Every 2 hr day and night. A rigid 2-hour schedule is unnecessary and may cause distress or inconvenience for the client.

D. After every drink or meal. While eating may trigger the gastrocolic reflex, forcing bathroom visits after every meal or drink is not always appropriate.

A. Assess respiratory rate and rhythm B. Pulse oximetry reading C. Assess bowel sounds D. Auscultate lung sounds E. Determine two touch discrimination in the lower extremities

Correct Answer is ["A","B","D"]

Explanation

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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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

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

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Correct Answer is ["A","B","D"]

Explanation

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