Question

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain.

Based on the client's clinical findings, which of the following actions should the nurse take?
Select all that apply.

Nurses' Notes
1200:
Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.
1230:
Client transported for abdominal x-ray.
1245:
Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.
1300:
Procedure explained to client who verbalized understanding.

Diagnostic Results
1245:
Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.


A. Assist the client to a left side-lying position with the right knee flexed.
B. Prepare the cleint for a chest x-ray.
C. Administer a cleansing enema.
D. Auscultate the client's bowel sounds.
E. Perform a manual digital examination of the client's rectum.
F. Administer oxycodone extended-release tablets.
G. Prepare the client for NG tube placement.

Answer 1

The nurse should assist the client into a left side-lying position to administer a hypertonic cleansing enema as prescribed, and auscultate the client's bowel sounds to assess for any contraindications to administering the enema.

Step-by-step explanation:

In this clinical scenario, the client reports abdominal pain and has not had a bowel movement for seven days while undergoing chemotherapy for pancreatic cancer. Given that there is no evidence of gastrointestinal obstruction from the x-ray and that the client has tried bisacodyl and magnesium citrate without success, the nurse should consider several actions from the list provided:

1. Assist the client to a left side-lying position with the right knee flexed: This is the standard position to administer an enema, as it allows the solution to flow by gravity along the natural curve of the sigmoid colon.
2. Administer a cleansing enema: The provider has prescribed a hypertonic enema after confirming there's no obstruction but a significant fecal load. An enema should help to clear the impaction.
3. Auscultate the client's bowel sounds: This is an essential step in assessing the motility and function of the bowels. It should be done before administering an enema to ensure there are no contraindications like complete bowel silence which may indicate a more serious underlying condition.

Options such as administering oxycodone (which the client is already taking), preparing for a chest x-ray, NG tube placement, or performing a manual digital examination are not indicated based on the provided clinical information. A chest x-ray is unrelated to the abdominal issue, oxycodone is for pain management and could exacerbate constipation, NG tube placement is generally for upper GI issues, and a manual examination should be performed with caution in chemotherapy patients due to their potential for low platelet counts and increased risk of bleeding.

Answer 2

The nurse should assist the client into a left side-lying position to administer a hypertonic cleansing enema as prescribed, and auscultate the client's bowel sounds to assess for any contraindications to administering the enema.

Step-by-step explanation:

In this clinical scenario, the client reports abdominal pain and has not had a bowel movement for seven days while undergoing chemotherapy for pancreatic cancer. Given that there is no evidence of gastrointestinal obstruction from the x-ray and that the client has tried bisacodyl and magnesium citrate without success, the nurse should consider several actions from the list provided:

1. Assist the client to a left side-lying position with the right knee flexed: This is the standard position to administer an enema, as it allows the solution to flow by gravity along the natural curve of the sigmoid colon.
2. Administer a cleansing enema: The provider has prescribed a hypertonic enema after confirming there's no obstruction but a significant fecal load. An enema should help to clear the impaction.
3. Auscultate the client's bowel sounds: This is an essential step in assessing the motility and function of the bowels. It should be done before administering an enema to ensure there are no contraindications like complete bowel silence which may indicate a more serious underlying condition.

Options such as administering oxycodone (which the client is already taking), preparing for a chest x-ray, NG tube placement, or performing a manual digital examination are not indicated based on the provided clinical information. A chest x-ray is unrelated to the abdominal issue, oxycodone is for pain management and could exacerbate constipation, NG tube placement is generally for upper GI issues, and a manual examination should be performed with caution in chemotherapy patients due to their potential for low platelet counts and increased risk of bleeding.