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 C

Explanation

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

A. Measure the amount of time the child can hear the sound. B. Obtain a tympanogram reading prior to initiating the test. C. Place a vibrating tuning fork on the top of the child's head. D. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.

Correct Answer is C

Explanation

Choice A rationale:

Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.

Choice B rationale:

Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.

Choice C rationale:

Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.

Choice D rationale:

Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.

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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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