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 B
Explanation
A. Weight loss is not a common or serious adverse effect of valproic acid. Valproic acid can cause weight gain, not weight loss.
B. Jaundice is a sign of liver damage, which is a serious and potentially fatal adverse effect of valproic acid. Valproic acid can impair fatty acid metabolism and mitochondrial function, leading to hepatotoxicity and steatosis. The nurse should monitor the client's liver function tests and report any signs of jaundice, such as yellowing of the skin or eyes, dark urine, or clay-colored stools .
C. Bradycardia is not a common or serious adverse effect of valproic acid. Valproic acid can cause cardiac arrhythmias, but they are usually tachycardic, not bradycardic.
D. Polyuria is not a common or serious adverse effect of valproic acid. Valproic acid can cause hypernatremia and hypocalcemia, which can affect urine output, but polyuria is not a specific symptom of these electrolyte imbalances.
Correct Answer is B, A, D, C
Explanation
B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.
A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.
D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.
C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.
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