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 A
Explanation
Choice A rationale:
The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.
Choice B rationale:
Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.
Choice C rationale:
Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.
Choice D rationale:
Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.
Correct Answer is ["13"]
Explanation
gtt/min = (mL/hr x gtt/mL) / 60
gtt/min = (50 x 15) / 60 gtt/min = 750 / 60 gtt/min = 12.5 Rounding to the nearest whole number, the answer is 13.
Therefore, the nurse should set the manual IV infusion to deliver 13 gtt/min.
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