A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury.
Which of the following actions should the nurse include in the plan of care?
Encourage a maximum fluid intake of 1,500 mL per day.
Increase the amount of refined grains in the client’s diet.
Provide the client with a cold drink prior to defecation.
Administer a cathartic suppository 30 min prior to scheduled defecation times.
The Correct Answer is D
This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or areflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.
Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.
Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.
Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injuries.
Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.
Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Inserting the catheter without applying suction is correct technique. Suction should only be applied while withdrawing the catheter to prevent mucosal trauma and hypoxia. Initiating suction during insertion can damage tracheal lining and cause bradycardia due to vagal stimulation. Allowing clean insertion without suction reduces injury risk and supports effective secretion removal on withdrawal with controlled suction time.
Choice B rationale: Waiting 2 minutes between suction passes is too long and may delay secretion clearance, risking hypoxia and secretion buildup. Best practice is to wait about 30 seconds to 1 minute or until the client recovers baseline oxygen saturation and heart rate. Prolonged intervals may lead to atelectasis or respiratory distress in patients with poor reserve, especially if suctioning is incomplete or secretions are copious.
Choice C rationale: Suctioning should be limited to 10–15 seconds per pass to reduce hypoxemia and bronchospasm risks. Applying suction for 15 seconds falls within the upper acceptable range, particularly if preoxygenation is done. Extended suction beyond this can decrease PaO₂ levels rapidly. Limiting the suction time ensures safer removal of secretions while minimizing trauma and preserving adequate oxygenation.
Choice D rationale: Encouraging the client to cough facilitates mobilization of secretions toward the upper airway, making suctioning more effective. Coughing also enhances airway clearance naturally and may reduce the number of required suction passes. It is a therapeutic action in tracheostomy care that supports pulmonary hygiene, helps prevent atelectasis, and can reduce the need for deep suctioning interventions.
Correct Answer is B
Explanation
Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
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