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 A
Explanation
A. Correct. The nurse should initiate continuous cardiac monitoring because a magnesium level of 2.7 mEq/L indicates hypermagnesemia, which can cause cardiac dysrhythmias, hypotension, and bradycardia.
B. Incorrect. The nurse should not administer potassium chloride to a client who has hypermagnesemia because it can worsen the condition by increasing the intracellular magnesium level and decreasing the serum calcium level.
C. Incorrect. The nurse should not provide a diet rich in legumes, nuts, and green vegetables to a client who has hypermagnesemia because these foods are high in magnesium and can increase the serum magnesium level.
D. Incorrect. The nurse should not monitor the client for tetany because tetany is a sign of hypomagnesemia, not hypermagnesemia. Hypomagnesemia can cause neuromuscular excitability, muscle spasms, and positive Chvostek's and Trousseau's signs.
Correct Answer is A
Explanation
A. Radial vein of the inner arm. This is correct because this site is easily accessible, has good blood flow, and has less risk of complications such as infection, thrombosis, or infiltration.
B. Great saphenous vein of the leg. This is incorrect because this site is not recommended for older adults due to poor circulation, increased risk of thrombophlebitis, and difficulty in monitoring.
C. Dorsal plexus vein of the foot. This is incorrect because this site is prone to edema, infection, and injury, and can interfere with mobility and comfort.
D. Basilic vein of the hand. This is incorrect because this site is more painful, has smaller veins, and can cause nerve damage or occlusion if not inserted carefully.
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