A patient is having trouble defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement?

Administering laxatives to the patient

Preparing to administer a cleansing enema

Withholding narcotic pain medication for at least 2 hours until the patient had a bowel movement successfully.

Raising the head of the bed to a semi or high Fowlers position

Answer and Explanation

The Correct Answer is D

Raising the head of the bed to a semi or high Fowler's position (sitting up at a 30-45-degree angle) can assist the patient in having a successful bowel movement while using a bedpan. This position helps to facilitate gravity, making it easier for the patient to bear down and evacuate their bowels.

Administering laxatives to the patient in (option A) is incorrect because laxatives are medications that help promote bowel movements. While they may be used in some cases of constipation, they might not be the immediate solution for a patient having difficulty using a bedpan.

Preparing to administer a cleansing enema in (option B) is incorrect because Enemas involve introducing liquid into the rectum to stimulate bowel movements. They are typically used for more severe cases of constipation or as part of a bowel preparation before certain medical procedures. For a patient who is simply having trouble using a bedpan while lying in bed, an enema may not be necessary or appropriate at this time.

Withholding narcotic pain medication for at least 2 hours until the patient had a bowel movement successfully in (option C) is incorrect because, while some pain medications, particularly opioids, can cause constipation as a side effect, withholding pain medication solely for this purpose may not be appropriate or safe. Pain management is essential for patient comfort and recovery, and the nurse should find other interventions to assist with bowel movements while maintaining appropriate pain control.

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Correct Answer is A

Explanation

Option A is the most appropriate choice. Applying a skin protective lotion after cleaning the backside can help moisturize and nourish the dry and thin perineal skin. It creates a barrier that helps protect the skin from further irritation and excoriation. It is important to choose a skin protective lotion specifically formulated for perineal care and suitable for older adults.

Let's go over the other options:

Option B is incorrect because taping an occlusive moisture barrier pad to the skin may not be necessary for mild excoriation and can potentially further irritate the skin. It is not the most appropriate intervention in this situation

Massage the skin with deep kneading pressure in (option C) is incorrect because deep kneading pressure may cause further irritation to the already dry and thin perineal skin, potentially worsening the excoriation. Gentle and cautious care should be taken to avoid excessive pressure or friction

Thoroughly scrub the skin with a washcloth and hypoallergenic soap in (option D) is incorrect because thoroughly scrubbing the skin with a washcloth and hypoallergenic soap can be too harsh for the already compromised perineal skin. It may cause further dryness, irritation, and damage to the skin. Gentle cleansing using mild, non-irritating soap and soft cloths or disposable wipes is more appropriate.

A. It is a priority for the nurse to focus on addressing the cause of the patient's anxiety and fear. B. patient's bowel sounds and presence of gas. C. family's questions about the procedure. D. patient's lung sounds and respiratory rate.

Correct Answer is A

Explanation

In this situation, the nurse's priority should be addressing the patient's anxiety and fear. The patient has expressed their fear and it is important for the nurse to provide emotional support and reassurance. By acknowledging the patient's fear and addressing it, the nurse can help alleviate anxiety and promote a sense of calmness before the surgery.

Assessing bowel sounds and the presence of gas (option B) is incorrect because it is only important in preoperative assessment. Addressing the patient's anxiety should take precedence as it directly affects the patient's emotional well-being.

The family's questions about the procedure (option C) is incorrect because it can only be addressed after attending to the patient's immediate emotional needs.

Assessing lung sounds and respiratory rate (option D) is incorrect because it is not the immediate priority in this scenario. Addressing the patient's anxiety should take precedence over respiratory assessment unless there are specific indications suggesting a respiratory issue.

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A patient is having trouble defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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A patient is having trouble defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement?