A patient reports abdominal pain.
An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.
Which of the following actions should the nurse take?

Assist the patient to a left side-lying position with the right knee flexed.

Prepare the patient for a chest x-ray.

Administer a cleansing enema.

Perform a manual digital examination of the patient’s rectum.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the patient to a left side-lying position with the right knee flexed is often used for rectal examinations or administering enemas, but it does not directly address the issue of a large amount of fecal material in the colon.

Choice B rationale

Preparing the patient for a chest x-ray would not be beneficial in this situation. A chest x-ray would not provide further information about the fecal material in the colon.

Choice C rationale

Administering a cleansing enema can help to remove the fecal material from the colon. This is a common treatment for fecal impaction.

Choice D rationale

Performing a manual digital examination of the patient’s rectum can help to assess the amount of fecal material present, but it would not alleviate the patient’s abdominal pain or remove the fecal material.

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Correct Answer is A

Explanation

Infiltration of an IV site is characterized by skin blanching, which is a whitening or lightening of the skin. This occurs when IV fluids or medications leak into the surrounding tissue from the vein. The area may also be cool to touch and swollen.

A. Hypertension B. Hypotension C. Tachycardia D. Bradycardia

Correct Answer is C

Explanation

Choice A rationale

Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.

Choice B rationale

Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.

Choice C rationale

Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.

Choice D rationale

Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.

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A patient reports abdominal pain.An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is receiving fluids through a peripheral IV catheter. Which of the following observations at the IV site should the nurse identify as signs of infiltration?

Correct Answer is A

Explanation

A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given. Heart rate of 110 bpm Complete the following sentence using the list of options. The patient exhibits symptoms of ________

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A patient reports abdominal pain.
An abdominal x-ray indicates a large amount of fecal material throughout the colon, but no evidence of gastrointestinal obstruction is observed.
Which of the following actions should the nurse take?