HESI Constipation

Question 1

Scenerio

Answer 1

A client on the medical surgical unit had an abdominal hysterectomy three days ago and is now reporting abdominal bloating, pain, and nausea. She is reluctant to eat or drink anything stating, “The smell of food makes me nauseated.” She informs the nurse that she feels constipated and has not passed a bowel movement since prior to surgery.

Question 2

The nurse observes the client’s abdomen is firm and distended the nurse performs an abdominal assessment. In which sequence should the nurse perform abdominal assessment?

Answer 2

Inspection, auscultation, percussion, palpation

rationale: percussion and palpation can alter abdominal findings so inspection and oscillation are indicated prior to percussion and palpation

Question 3

Which assessment is most important for the nurse to perform?

Answer 3

Auscultate bowel sounds
rationale: the subject data reported by the client (abdomen firm and distended) suggests that she may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds

Question 4

Which is the most important action for the nurse to perform when assessing bowel sounds?

Answer 4

1. Listen up to 5 minutes when auscultating for bowel sounds
   rationale: the nurse must listen for up to 5 minutes before determining what type of bowel sounds are present
2. Begin auscultation in the right lower quadrant
   rationale: the nurse should oscillate in the right lower quadrant and then proceed to the other quadrants

Question 5

The nurse auscultates for the client’s bowel sounds and hears faint gurgling after three minutes what assessment finding should the nurse document?

Answer 5

Hypoactive bowel sounds
rationale: normally vowel sounds are heard 5 to 35 times per minute when bowel sounds are heard only after listening for three minutes they are recorded as hypoactive

Question 6

While the nurse is completing the assessment the client begins to cry and moan “I just knew something would go wrong.” how should the nurse respond?

Answer 6

“Tell me what is making you feel so upset”

rationale: this open-ended statement encouraged the client to express further concerns and fears

Question 7

which response by the nurse will encourage continue verbalization by the client?

Answer 7

” it sounds as if you had another experience that did not go well.”
Rationale: This open-ended statement encourages the client to express further concerns and fears

Question 8

The nursing informs the client that she has developed constipation. The client tells the nurse “I hate hospitals because nobody ever tells you what’s happening and you end up with all these things going wrong.”

The client continues “I did everything My HCP told me to do the surgery must’ve caused this they must have made a mistake”which explanation by the nurses accurate?

Answer 8

Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved

Rationale: constipation, secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis

Question 9

What postoperative medication is most likely to contribute to constipation?

Answer 9

Morphine sulfate and opioid analgesic

Rationale: the most common adverse effective opioid analgesic is constipation

Question 10

The nurse instruct the client on which activity that would minimize risk for constipation?

Answer 10

Getting out of bed and ambulating

Rationale: immobility is a major risk for constipation

Question 11

What impact does insufficient fluid intake have on the clients bowel patterns?

Answer 11

This inadequate fluid intake has contributed to your constipation
Rationale: an adult needs 1400 to 2000 ML of fluid daily to prevent hardening of the stool

Question 12

The clients HCP has prescribed two medication‘s for constipation: a one time dose of bisacodyl suppository, PR and docusate sodium 100 mg PO daily. The nurse explains that the bisacodyl suppository will have a laxative effect before administering the rectal suppository. How should the client be positioned?

Answer 12

Sims
Rationale: the client should be in a Sims position on the left side with the knees flexed

Question 13

When administering the rectal suppository, the nurse asked the client to take several slow, deep breaths. What is the rationale for this instruction?

Answer 13

Relaxes the anal sphincter and reduces discomfort
Rationale: deep breathing, promotes, relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted

Question 14

After administering the rectal suppository, how should the nurse document this action?

Answer 14

0 900. One bisacodyl suppository administered per rectum for constipation as prescribed.
Rationale: this documentation correctly identifies the medication, the dose, the time and the route of administration, as well as the reason for administrating the medication

Question 15

Which statement provides the best documentation, describing the outcome, from the suppository administration?

Answer 15

1100. Client reports producing six, 0.25 inch, hard pellets of brown stool, falling suppository administration.

Question 16

The next day, the client still has not expelled additional feces. To determine the presence of a fecal impaction, the nurse would prepare the client for which probable prescribed procedure?

Answer 16

1. Radiographic examination.
2. Digital rectal examination.
   Rationale: digital, rectal, or radiographic examination is the procedure performed to assess for the presence of a fecal impaction

Question 17

The UAP obtain sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy which action is the most important for the nurse to implement?

Answer 17

Ask the UAP to assist with the client positioning while the nurse performs the procedure while teaching the UAP about the correct supplies needed
Rationale: this task should not be delegated to the UAP because it is an invasive procedure that places a client at risk. UAP can be assigned to assist the nurse with client positioning. Having UAP assist in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should non-sterile exam gloves, which are less costly than sterile, gloves, and lubricant for this procedure.

Question 18

While performing the digital rectal exam, the nurse understands that the client may experience vagal nerve stimulation. This can result in which change vital signs?

Answer 18

Decreased pulse rate
Rationale: vagal nerve stimulation can cause a reflex flowing of the heart rate

Question 19

The nurse notifies the HCP of the presence of fecal impaction and reserves verbal prescription over the telephone for soap, suds enema administration
One receiving the verbal prescription over the telephone the nurse rep preached the prescription back to the HCP who sounds angry and shouts, “Are you questioning my prescription?” which approach brother nurse is the best response to the angry HCP?

Answer 19

“ I want to ensure that I transcribe this prescription correctly to avoid error.”
Rationale: this assertive response teaches the HCP, the purpose of repeating back verbal prescriptions

Question 20

What action should the nurse implement?

Answer 20

Administer the enema as prescribed and obtain the HCP signature the next day

Question 21

The nurse administer the prescribed, soapsuds enema to illicit irritation to the colon to help with constipation. During the enema, the client begins to experience abdominal cramping. What actions should the nurse take to relieve abdominal cramping?

Answer 21

1. Slow the infusion rate.
   Rationale: slowing the rate of the enema infusion and reassessing, the client should reduce or stop the clients abdominal cramping
2. Roll the clamp to stop the enema until cramping subsides
   Rationale: actual stop, or slow down cramping when cramping decreases start enema again by slowly releasing the clamp to begin flow

Question 22

The client informed the nurse she is interested in the amount of fluid administered via the enema but does not understand milliliters. The client received a total volume of 725 mL. How will the nurse accurately explain the amount of fluid using household measurements?

Answer 22

3 cups

Rationale: the conversion factor needed are as follows: 30 mL equals = 1 ounce, and 1 cup = 8 ounces. 725 mL /30 = 24 ounces/ 8 = 3 cups

Question 23

Nurse encourages the client to increase her daily, oral fluid intake to 2 L of fluid for the next few days. This is equivalent to how many 8 ounce cups of fluid daily?

Answer 23

Eight

Rationale: 1 ounce = 30 mL, 8ounce cup contains – 8×30 mL = 240 mL, 2 L = 2000 mL, 2000 mL/240 mL = 8.33 cups/day

Question 24

The remainder of the client surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity and has regular bowel movement. She eats a regular diet with no restrictions and ask the client about foods that promote bowel regularity. What type of foods should the nurse recommend?

Answer 24

With fiber

Rationale: foods, with fiber, accelerates the passage of food through the intestines, which is important for bowel regularity

Question 25

The nurse uses the hospital breakfast menu as of teaching tool, which breakfast selection by the nurse indicates that she understands teaching about dietary measures to promote bowel regularity?

Answer 25

Orange juice and oatmeal with raisins

Rationale: whole-grain, cereals, and fruits are good sources of fiber, which is beneficial to bowel regularity