Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
Abdominal girth.
Breath sounds.
Bowel sounds.
Vital signs.
The Correct Answer is D
Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.
This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.
These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.
Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.
Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.
Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.
Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.
Correct Answer is B
Explanation
The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain.
Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system1.
Therefore, the nurse should document the finding as neuropathic pain.
Choice A is not correct because acute pain is a general term that does not specify the type of pain experienced by the patient.
Choice C is not correct because visceral pain refers to pain that originates from internal organs.
Choice D is not correct because nociceptive pain refers to pain caused by tissue damage or injury.
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