A nurse is developing a plan of care for a client diagnosed with constipation. Which nursing interventions should be included in planning? (Select all that apply).
Encourage high-fiber food choices.
Increase fluid intake to 2,000 mL per day.
Encourage ambulation several times per day.
Administer antacids as necessary per bowel management program.
Correct Answer : A,B,C
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.
Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.
Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.
Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.
They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.
Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
Correct Answer is B
Explanation
To find the rate of the pump in ml/hour, you need to first convert the client’s weight from pounds to kilograms. You can do this by dividing the weight by 2.2046 or multiplying it by 0.454.
For example:
297 lbs / 2.2046 = 134.72 kg or 297 lbs x 0.454 = 134.72 kg
Then, you need to multiply the client’s weight in kilograms by the ordered dose in units/kg/hour to get the total units per hour.
For example:
134.72 kg x 12 units/kg/hour = 1616.64 units/hour
Next, you need to set up a proportion to find the rate of the pump in ml/hour using the supplied medication concentration.
For example:
25,000 units / 500 ml = 1616.64 units / X ml Cross-multiply and solve for X:
25,000 x X = 808320 X = 808320 / 25000 X = 32.33 ml/hour
Finally, you need to round your answer to the nearest tenth of a ml/hour as per the medication administration guidelines.
For example:
32.33 ml/hour ≈ 32.3 ml/hour
Therefore, the rate of the pump is 32.3 ml/hour.
Choice A is wrong because it uses a different conversion factor for pounds to kilograms (1 lb = 0.5 kg) which is not accurate.
Choice C is wrong because it uses a different ordered dose (10 units/kg/hour) which is not what the provider has written.
Choice D is wrong because it uses a different supplied medication concentration (20,000 units in 500 ml) which is not what is available.
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