A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?
"What types of foods have you been eating?”
"Are you using stool softeners or laxatives?”
"Have you been passing gas?”
"Have you had small liquid stools?”
The Correct Answer is D
The correct answer is choice d. “Have you had small liquid stools?”
Choice A rationale:
While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.
Choice B rationale:
Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.
Choice C rationale:
Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.
Choice D rationale:
Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale:
Count the client's radial and apical pulses simultaneously with another nurse. Rationale: In the presence of an irregular heart rate, a pulse deficit might indicate a discrepancy between the peripheral (radial) and central (apical) pulses. Counting the pulses simultaneously with another nurse helps to accurately assess this deficit. By comparing the two pulse rates, the nurse can identify if there is a difference, which might indicate inadequate circulation or irregular heartbeats that aren't effectively transmitting to the peripheral arteries.
Choice B rationale:
Calculate the client's pulse for 30 seconds and multiply by 2. Rationale: While calculating the pulse rate for 30 seconds and then multiplying by 2 is a valid method to determine the heart rate, it doesn't address the specific concern of a pulse deficit. This approach might help in assessing the overall heart rate but doesn't provide information about potential irregularities or discrepancies between peripheral and central pulses.
Choice C rationale:
Assist the client to a side-lying position. Rationale: Assisting the client to a side-lying position doesn't directly relate to the assessment of a pulse deficit. The position of the client wouldn't significantly impact the assessment of irregular heart rates or pulse deficits.
Choice D rationale:
Auscultate the area of the client's chest over the Erb's point. Rationale: Auscultating the area of the client's chest over the Erb's point is a technique used to assess heart sounds, particularly the S2 heart sound. This technique is not relevant to assessing a pulse deficit. It can provide information about heart valve function but doesn't help in evaluating a discrepancy between peripheral and central pulses.
Correct Answer is C
Explanation
The correct answer is choice C. "I will remove all stuffed animals from my baby's crib."
Choice A rationale:
"I will place my baby on her side to sleep." Placing a baby on their side to sleep is not recommended as it increases the risk of sudden infant death syndrome (SIDS). The back sleep position is the safest for infants to reduce the risk of SIDS.
Choice B rationale:
"I should avoid giving my baby a pacifier." Using a pacifier during sleep actually has a protective effect against SIDS. It's recommended to offer a pacifier at naptime and bedtime after breastfeeding is well-established.
Choice C rationale:
"I will remove all stuffed animals from my baby's crib." This is the correct answer as it demonstrates an understanding of safe sleep practices. Soft bedding, including stuffed animals, can pose a suffocation hazard for infants. A clear and uncluttered crib is recommended for safe sleep.
Choice D rationale:
"I will cover my baby with a light blanket when she is sleeping." The use of blankets, even lightweight ones, in an infant's sleep environment is associated with an increased risk of SIDS. It's advised to keep the crib free from blankets, pillows, and other loose items.
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