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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.
Correct Answer is C
Explanation
Choice A rationale
Saying “I could not arrive any sooner. What can I do for you?” may come off as defensive and does not acknowledge the client’s feelings of frustration.
Choice B rationale
Saying “We had an emergency on the unit and that was a priority, but now I’m here.”. may make the client feel less important and does not acknowledge their feelings of frustration.
Choice C rationale
Saying “That must be frustrating for you. How can I help you right now?” acknowledges the client’s feelings of frustration and offers assistance, which is an appropriate response.
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