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 playpen is a portable enclosure that provides a confined space for a child to play in. It can be useful for keeping a child safe and supervised when the caregiver is busy or needs a break, but it should not be used as a substitute for active play or interaction with the caregiver or others.
- A 2-year-old child is in the developmental stage of toddlerhood, which is characterized by rapid physical, cognitive, social, and emotional growth. Toddlers are curious and eager to learn about the world around them, and they need opportunities to explore, experiment, and manipulate objects and materials. They also need stimulation, guidance, and feedback from their caregivers and peers to develop their language, problem-solving, and social skills.
- Keeping a 2-year-old child in a playpen for long periods of time or to prevent them from getting dirty can have negative effects on their development and well-being. It can limit their physical activity, creativity, and independence, and it can cause boredom, frustration, or resentment . It can also interfere with their atachment and bonding with their caregiver, as well as their self-esteem and self-image.
- Therefore, the practical nurse (PN) should use the statement "Children need time to actively explore their environment" in responding to this concern about using a playpen. This statement reflects the developmental needs and rights of the child, and it encourages the caregiver to provide a more stimulating and supportive environment for the child. It also implies that getting dirty is not a problem, but rather a natural and healthy part of play and learning.
- Therefore, option D is the correct answer, while options A, B, and C are incorrect. Option A is incorrect because it is judgmental and may offend or discourage the caregiver.
Option B is incorrect because it is not true that playpens provide a sense of security for the child, as they may feel isolated or restricted in them.
Option C is incorrect because it is not true that playpens provide a safe environment for a toddler, as they may pose hazards such as entrapment, suffocation, or injury from falling or climbing out of them.
Correct Answer is A
Explanation
A. Correct. The nurse should initiate seizure precautions for a client who is at 33 weeks of gestation and has severe gestational hypertension, which is a blood pressure of 160/110 mm Hg or higher on two occasions at least 4 hr apart, or once with signs of end-organ damage. Severe gestational hypertension can lead to preeclampsia, which is a condition characterized by hypertension, proteinuria, and edema, and can progress to eclampsia, which is a life-threatening complication that involves seizures.
B. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 16 weeks of gestation and has a hydatidiform mole, which is an abnormal growth of placental tissue that resembles grape-like clusters. A hydatidiform mole can cause vaginal bleeding, hyperemesis gravidarum, and elevated human chorionic gonadotropin levels, but it does not increase the risk of seizures.
C. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 28 weeks of gestation and is experiencing vaginal bleeding, which can have various causes such as placenta previa, placental abruption, or cervical trauma. Vaginal bleeding can indicate a potential hemorrhage, but it does not increase the risk of seizures.
D. Incorrect. The nurse does not need to initiate seizure precautions for a client who is at 36 weeks of gestation and has a positive group B streptococcal culture, which means that the client has bacteria in their vagina or rectum that can cause infection in the newborn during delivery. A positive group B streptococcal culture requires antibiotic prophylaxis during labor, but it does not increase the risk of seizures.
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