Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Evaluate the client's ability to recognize the urge to defecate.

Determine the frequency and consistency of bowel movements.

Observe the skin integrity of the client's rectal and sacral areas.

Assess the client's strength in moving and turning in the bed.

Answer and Explanation

The Correct Answer is B

A) Evaluate the client's ability to recognize the urge to defecate: Assessing the client's ability to recognize the urge to defecate is important for promoting independence in toileting. However, this assessment may not directly indicate the need for administering a laxative. It is more relevant for clients who are able to ambulate or have control over their bowel movements.

B) Determine the frequency and consistency of bowel movements: Assessing the frequency and consistency of bowel movements provides valuable information about the client's bowel function and helps determine the need for a laxative. It allows the nurse to establish a baseline and evaluate the effectiveness of interventions. Understanding the client's typical bowel pattern is crucial before administering a laxative to avoid overmedication or potential complications such as diarrhea or fecal impaction.

C) Observe the skin integrity of the client's rectal and sacral areas: Assessing skin integrity in the rectal and sacral areas is crucial for preventing pressure ulcers, especially in bedfast clients. However, it is not directly related to the need for administering a laxative.

D) Assess the client's strength in moving and turning in the bed: While assessing the client's strength and mobility is important for overall care and prevention of complications related to immobility, it may not be directly related to the need for administering a laxative. This assessment is more relevant for preventing complications such as pressure ulcers and maintaining musculoskeletal function.

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Correct Answer is C

Explanation

A) Taking the medication one hour after meals and other medications may help prevent interference with the absorption of nutrients or other medications. However, it is not a specific instruction related to the administration of bulk-forming laxatives.

B) Remaining upright for thirty minutes following drug administration is a common instruction for medications that may cause esophageal irritation or reflux. However, it is not typically necessary for bulk-forming laxatives, which work primarily in the colon rather than the esophagus or stomach.

C) Following medication administration with an additional glass of water is the correct instruction for self-administration of bulk-forming laxatives. These laxatives absorb water in the intestines, which helps to soften the stool and promote bowel movements. Adequate hydration is essential to prevent the bulk-forming laxative from causing intestinal obstruction.

D) Avoiding the intake of dairy products while using the medication is not a specific instruction related to the administration of bulk-forming laxatives. Bulk-forming laxatives are generally well-tolerated and do not interact with dairy products. However, increasing fluid intake, particularly water, is essential to prevent constipation and ensure the effectiveness of the medication.

A. Use a twice a week dosing schedule. B. Take the medication early in the day. C. Stand and sit up slowly. D. Reduce daily fluid intake.

Correct Answer is C

Explanation

A) Tamsulosin is typically administered once daily, not on a twice-weekly dosing schedule. Instructing the client to adhere to the prescribed dosing frequency is essential for maintaining therapeutic blood levels of the medication and optimizing its effectiveness in managing urinary retention associated with benign prostatic hyperplasia (BPH).

B) While the timing of medication administration can impact its effectiveness, taking tamsulosin early in the day versus later in the day may not significantly affect its therapeutic action. The key consideration with tamsulosin is to maintain consistency in timing to ensure a steady plasma concentration of the drug.

C) Instructing the client to stand and sit up slowly is crucial because tamsulosin, as an alpha-blocker, can cause orthostatic hypotension, especially when first starting the medication or when increasing the dosage. By advising the client to change positions slowly, the nurse helps prevent falls and dizziness, which are common side effects associated with sudden drops in blood pressure.

D) Reducing daily fluid intake is not advisable, especially for a client with urinary retention. Maintaining adequate hydration is essential for overall health and urinary function. Tamsulosin works by relaxing the smooth muscles of the prostate and bladder neck, facilitating urine flow, but it does not directly affect fluid intake requirements.

Therefore, the most important instruction for the nurse to provide is to stand and sit up slowly to minimize the risk of orthostatic hypotension and associated complications.

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Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instruction should the nurse include when teaching a client about self-administration of a bulk-forming laxative?

Correct Answer is C

Explanation

A client is receiving tamsulosin for the management of urinary retention due to benign prostatic hyperplasia (BPH), Which instruction is most important for the nurse to provide?

Correct Answer is C

Explanation

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