A nurse is digitally removing stool that is impacted from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:
Blood pressure increases from 110/84 to 118/88 mm Hg.
Temperature increases from 98.8°F to 99.0°F.
Pulse rate decreases from 78 to 52 beats/min.
Respiratory rate increases from 16 to 24 breaths/min.
The Correct Answer is C
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A The shape of the abdomen is a physical assessment finding and not subjective
information provided by the patient. It involves the nurse's observation of the patient's abdomen during the examination.
Choice B Bowel sounds are also physical assessment findings that involve the nurse listening to the patient's abdomen using a stethoscope.
Choice C This is the correct answer. Abdominal cramping and discomfort are subjective symptoms reported by the patient and are relevant to the patient's bowel elimination status. Choice D Like the shape of the abdomen, the distention of the abdomen is a physical assessment finding and not subjective information provided by the patient.
Correct Answer is A
Explanation
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
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