A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

"What types of foods have you been eating?”

"Are you using stool softeners or laxatives?”

"Have you been passing gas?”

"Have you had small liquid stools?”

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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Correct Answer is A

Explanation

The correct answer is choice a. "It must be difficult facing this type of surgery.”

Choice A rationale: This statement acknowledges the client’s feelings and provides emotional support, which is crucial in reducing anxiety and promoting a sense of understanding and empathy.

Choice B rationale: While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.

Choice C rationale: Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.

Choice D rationale: Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.

A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hr. C. Document intake and output. D. Flush the tubing with 30 mL of water after each feeding.

Correct Answer is A

Explanation

The correct answer is Choice A - Measure the client's gastric residual before each feeding.

Choice A rationale:

The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.

Choice B rationale:

Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.

Choice C rationale:

Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.

Choice D rationale:

Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.

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A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Correct Answer is A

Explanation

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