A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Place the client in the lithotomy position.

Elicit a vagal response by performing gentle rectal stimulation.

Administer oral bisacodyl 30 min prior to the procedure.

Insert a lubricated gloved finger and advance along the rectal wall.

Answer and Explanation

The Correct Answer is D

A. Incorrect. The lithotomy position is not appropriate for this procedure, as it can cause discomfort and embarrassment to the client. The nurse should place the client in a left lateral Sims' position with the right knee flexed for better access to the rectum and to reduce pressure on the abdominal organs.

B. Incorrect. The nurse should avoid eliciting a vagal response, as it can cause bradycardia, hypotension, and syncope in some clients. The nurse should monitor the client's vital signs and stop the procedure if signs of vagal stimulation occur.

C. Incorrect. Oral bisacodyl is a stimulant laxative that can cause abdominal cramping, diarrhea, and electrolyte imbalance. It is not indicated for fecal impaction, as it can worsen the condition by increasing the bulk and hardness of the stool. The nurse should administer an enema or a stool softener before attempting digital evacuation.

D. Correct. The nurse should insert a lubricated gloved finger and advance along the rectal wall, breaking up the stool and removing it in small pieces. The nurse should use gentle pressure and avoid injuring the rectal mucosa. The nurse should also explain the procedure to the client and obtain informed consent before performing it.

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Correct Answer is B

Explanation

A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.

B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.

C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.

D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.

A. Turn off the CPM machine during mealtime. B. Maintain the client's affected hip in an externally rotated position. C. Instruct the client how to adjust the CPM settings for comfort. D. Store the CPM machine under the client's bed when not in use.

Correct Answer is A

Explanation

A. Correct. The nurse should turn off the CPM machine during mealtime, as it can interfere with the client's ability to eat and drink comfortably. The nurse should also turn off the CPM machine when transferring or repositioning the client, or when performing wound care or other interventions on the affected leg.

B. Incorrect. The nurse should maintain the client's affected hip in a neutral position, as external rotation can cause malalignment of the prosthesis and impair healing. The nurse should use pillows or wedges to support the leg and prevent rotation or abduction of the hip joint.

C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings, as this can compromise the prescribed range of motion and speed of the device. The nurse should follow the provider's orders and check with them before making any changes to the CPM settings. The nurse should also monitor the client's pain level and administer analgesics as needed to facilitate compliance with the therapy.

D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this can pose a safety hazard and damage the equipment. The nurse should place the CPM machine on a stable surface near the bed and ensure that it is plugged into a grounded outlet and has adequate battery backup in case of power failure.

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A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is A

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