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 A

Explanation

"I will not allow anyone to smoke near my baby."

A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.
B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.
C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.
D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.

A. Evaluate the changes the partner requests B. Review the client's plan of care C. Analyze other reports of poor care to look for trends D. Ask the partner to list specific concerns

Correct Answer is D

Explanation

Ask the partner to list specific concerns.

A. Evaluate the changes the partner requests: This is incorrect because it is not the first action to take. The charge nurse should first listen to and acknowledge the partner's complaints before evaluating any changes or solutions.
B. Review the client's plan of care: This is incorrect because it is not the first action to take. The charge nurse should first understand what aspects of care are unsatisfactory for the partner and why they feel that way.
C. Analyze other reports of poor care to look for trends: This is incorrect because it is not relevant to this situation. The charge nurse should focus on addressing this specific case of dissatisfaction rather than looking for general patterns or issues.
D. Ask the partner to list specific concerns: This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.

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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

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Correct Answer is D

Explanation

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