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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.
B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.
C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.
D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.
Correct Answer is B
Explanation
A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
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