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 C

Explanation

The proper length of the needle to administer a subcutaneous injection depends on the amount of adipose tissue over the muscle.

The needle should be long enough to reach the subcutaneous layer but not so long that it penetrates the muscle. The needle gauge and length vary depending on the patient’s size and the injection site

Choice A is wrong because the age of the client does not determine the needle length.

However, age may affect the amount of adipose tissue and muscle mass, which are factors to consider when choosing a needle length.

Choice B is wrong because the viscosity of the solution does not determine the needle length. However, viscosity may affect the needle gauge, which is the diameter of the needle.

Thicker solutions may require larger gauge needles to allow easier flow.

Choice D is wrong because the quantity of the solution does not determine the needle length.

However, quantity may affect the syringe size, which is the volume of medication that can be held by the syringe.

The syringe size should match the prescribed dose as closely as possible to ensure accuracy and ease of measurement.

A. Advise the client to stay in bed and only get up with assistance. B. Place the call bell in reach and respond promptly when activated. C. Maintain the bed at working height for convenience when doing post op vital signs. D. Keep the lights off to encourage client to rest and recuperate. E. Attach the drain to wall suction and keep the tubing pinned to the client’s gown.

Correct Answer is ["B"]

Explanation

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.

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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 criterion should a nurse use to determine the proper length of the needle to administer a subcutaneous (subcut) medication?

Correct Answer is C

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A client has returned to the medical surgical unit with a Jackson-Pratt surgical drain. What safety measures should the nurse use to prevent client injury? (Select all that apply).

Correct Answer is ["B"]

Explanation

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