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 C
Explanation
Choice A rationale
Tuberculosis is a serious infectious disease that affects the lungs. However, it does not typically cause lung hyperinflation.
Choice B rationale
Bronchitis is an inflammation of the bronchial tubes. While it can cause symptoms similar to those described, it does not typically cause lung hyperinflation or localized pneumonia in the left upper lobe.
Choice C rationale
Pneumonia is an infection that inflames the air sacs in one or both lungs. The client’s symptoms of a productive cough with thick yellow sputum, crackles in the left upper lobe, and decreased breath sounds at bases bilaterally are consistent with pneumonia. The chest x-ray showing left upper lobe pneumonia confirms this diagnosis.
Choice D rationale
Asthma is a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe. While asthma can cause lung hyperinflation, it does not typically cause localized pneumonia in the left upper lobe.
Correct Answer is A
Explanation
Choice A rationale
Pressing gently on the tragus of the ear after administering the medication can help the medication to reach the inner ear.
Choice B rationale
Packing a small piece of cotton deep into the patient’s ear canal is not recommended as it can cause damage to the ear.
Choice C rationale
Moving the patient’s auricle down and back towards their head is not necessary when administering otic medication.
Choice D rationale
Tilting the patient’s head backward for 5 minutes is not required when administering otic medication.
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