A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

A physician’s order is needed

Use a lubricated index finger to break up some of the mass and remove it

Sterile gloves should be used for the procedure

The mass should be removed as a whole

The patient should be in the side lying position.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.

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Correct Answer is A

Explanation

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

A. Purplish-colored stoma B. Shiny, moist stoma C. Stoma oozing red drainage D. "Budded" stoma

Correct Answer is A

Explanation

Choice A rationale: A purplish-colored stoma may indicate compromised blood supply and should be reported to the provider.
Choice B rationale: A shiny, moist stoma is a healthy characteristic of a colostomy. Choice C rationale: Stoma oozing red drainage is a normal finding after colostomy surgery.
Choice D rationale: "Budded" stoma is not a recognized term related to colostomy assessment.

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A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving heat applications using a heating pad. Which of the following actions should the nurse take when applying the pad?

Correct Answer is A

Explanation

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

A client with a urinary tract infection is to be discharged from the healthcare facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client makes which statement?

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but the care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

The nurse is caring for a patient with a fractured left leg and is using crutches. Which statement indicates the patient has correct understanding of how to properly use her crutches?

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?

The patient is receiving 30 mg of citalopram daily for depression. Citalopram is available in 20 mg scored tablets. How many tablets should be administered? (Round to the nearest tenth.)