University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2021
Views:

350

Pages:

3
Author:

Marilyn James

Hesi Case Study: Constipation 1. Which sequence Answer:Inspection, auscultation, percussion, palpation 2. which assessment is most important? Answer:auscultate bowel sounds 3. what is most important action when assessing bowel sounds? Answer: listen for up to five minutes begin in right lower quadrant 4. hears faint gurgling sounds after 3 minutes. what should nurse document Answer:hypoactive bowel sounds 5. janelle is crying. "i knew something would go wrong" how to respond? Answer:tell me what is making you feel so upset 6. which response will encourage continued verbalization Answer:it sounds as if you have had other experiences that did not go well 7. i did everything they said to do, there must've been a mistake. which explanation is accurate? Answer:explain multiple factors, even when surgical outcome is achieved 8. which post op med is most likely to cause constipation Answer:morphine sulfate 9. what impact does fluid intake have on janelles bowel patterns? (1,000 mL's in last 24hrs) Answer:inadequate fluid intake had contributed 10. what other questions should the nurse ask? Answer:how often do you get out of bed and walk 11. which response accurately describes barium swallow Answer:barium liquid is swallowed and a series of x-rays are taken 12. what nursing diagnosis should the nurse include in janelles poc? Answer:constipation r/t surgery and anesthesia 13. how will the nurse explain to janelle the action of the laxative? (bisacodyl suppository) Answer:soften stool, distend the rectum to expel the stool 14. nurse admins dose of docusate sodium. primarily alters? Answer:consistencey 15. how should pt be positioned for rectal suppository Answer:sims 16. when administering rectal suppository, janelle is asked to take slow deep breaths. why? Answer:relax the anal sphincter and reduce discomfort 17. what to document when administering rectal suppository Answer:0900. one bisacodyl suppository administered per rectum for constipation, as prescribed 18. what documentation for outcome of suppository? Answer:1100. client produced six 1/4 inch hard pellets of brown stool following suppository admin 19. what procedure to determine presence of fecal impaction? Answer: digital rectal exam radiographic exam 20. UAP offers to do the procedure..what should the nurse implement Answer:ask uap to assist w/ positioning while teaching 21. vagal nerve stimulation can result in what VS change Answer:decreased pulse rate 22. HCP gives verbal prescription over phone..what action should the nurse take? Answer:admin enema as prescribed, get signature next day 23. hcp gets mad.." r u questioning me?" what response? Answer:i want to ensure i transcribe correctly 24. what actions to relieve abdominal cramping Answer: slow rate of infusion roll slam to stop enema until cramps stop 25. what tasks can the rn delegate to the UAP Answer: assist the client w/ bed bath and hygiene if req. assist the client who vomited w/ mouth care after rn admins antiemetic 26. fluid to h/h measurements Answer:3 cups 27. 2 liters to ~ how many 8 oz cups Answer:8-9 28. what type of diet should the nurse recommend Answer:high fiber 29. what dietary selection by Janelle indicates that she understands Answer: oj and oatmeal with raisins