A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?
Place the client in the lithotomy position.
Elicit a vagal response by performing gentle rectal stimulation.
Administer oral bisacodyl 30 min prior to the procedure.
Insert a lubricated gloved finger and advance along the rectal wall.
The Correct Answer is D
- A. Incorrect. The lithotomy position is not appropriate for this procedure, as it can cause discomfort and embarrassment to the client. The nurse should place the client in a left lateral Sims' position with the right knee flexed for better access to the rectum and to reduce pressure on the abdominal organs.
- B. Incorrect. The nurse should avoid eliciting a vagal response, as it can cause bradycardia, hypotension, and syncope in some clients. The nurse should monitor the client's vital signs and stop the procedure if signs of vagal stimulation occur.
- C. Incorrect. Oral bisacodyl is a stimulant laxative that can cause abdominal cramping, diarrhea, and electrolyte imbalance. It is not indicated for fecal impaction, as it can worsen the condition by increasing the bulk and hardness of the stool. The nurse should administer an enema or a stool softener before attempting digital evacuation.
- D. Correct. The nurse should insert a lubricated gloved finger and advance along the rectal wall, breaking up the stool and removing it in small pieces. The nurse should use gentle pressure and avoid injuring the rectal mucosa. The nurse should also explain the procedure to the client and obtain informed consent before performing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.
Choice B rationale:
A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line. However, this choice specifies the right PICC line, so the correct answer is choice C, which addresses the situation of a client with an arteriovenous shunt in the left lower forearm.
Choice C rationale:
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.
Choice D rationale:
A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.
Correct Answer is A
Explanation
- A. "We can expect the hospice nurse to provide support for us after our mother's death." This statement indicates that the family understands that hospice care includes bereavement services for up to one year after the death of a loved one.
- B. "A hospice nurse will come to the house each time our mother needs pain medication." This statement indicates that the family does not understand that hospice care involves teaching them how to administer pain medication and other comfort measures to their mother at home.
- C. "Now that my mother is receiving hospice services, we will not be able to get respite care." This statement indicates that the family does not understand that hospice care offers respite care, which allows them to take a break from caregiving for a short period of time.
- D. "Hospice care focuses on arranging treatment that will prolong our mother's life." This statement indicates that the family does not understand that hospice care focuses on providing palliative care, which aims to relieve pain and suffering, rather than curative treatment, which aims to extend life.
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