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 A
Explanation
To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.
This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.
Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.
Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.
Correct Answer is B
Explanation
The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.
Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.
Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.
Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.
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