Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

Formed stool two times per day, every day, for one week.

Use of soap sud enemas weekly to promote elimination.

Continued use of laxatives at half of the prescribed dose.

A formed, soft stool at regular intervals without the use of a laxative.

Answer and Explanation

The Correct Answer is A

Formed stool two times per day, every day, for one week. This indicates that bowel training is attaining the desired outcome because it shows regularity and consistency of bowel movements without the use of laxatives or enemas.

Choice B is wrong because soap sud enemas are not recommended for bowel training as they can irritate the bowel and cause fluid and electrolyte imbalance.

Choice C is wrong because continued use of laxatives can inhibit the natural defecation reflexes and cause dependency.

Choice D is wrong because a formed, soft stool at regular intervals without the use of a laxative is a normal defecation pattern, not an indication of fecal incontinence.

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Correct Answer is B

Explanation

Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.

The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.

Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.

Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.

Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.

Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.

A. Increased heart rate. B. Decreased blood pressure. C. Increased temperature. D. Hypoactive muscle responses. E. Alert and oriented.

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

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

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Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should a nurse perform when administering an intramuscular injection via the Z- track method?

Correct Answer is B

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

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

Explanation

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