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 B

Explanation

A. Hypoxemia is a condition of low oxygen levels in the blood. PEEP can actually improve oxygenation by preventing alveolar collapse and increasing functional residual capacity.

B. Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.

C. Malignant hypertension is a severe form of high blood pressure that can cause organ damage and stroke. PEEP can cause a transient increase in blood pressure due to increased intrathoracic pressure, but it does not cause malignant hypertension.

D. Atelectasis is a condition of partial or complete lung collapse due to alveolar collapse or obstruction. PEEP can prevent or treat atelectasis by maintaining positive pressure in the airways and alveoli.

A. Alternate eating solid foods and liquids B. Eat every 2 to 3 hr C. Drink warm ginger ale when nauseated D. Increase intake of high-fat foods E. Recommended actions

Correct Answer is ["A","B","C","E"]

Explanation

Correct answer: A, B, C, E

Rationale:

A: Alternate eating solid foods and liquids is recommended. This can help prevent dehydration and malnutrition, as well as reduce the risk of vomiting by avoiding overfilling the stomach.
B: Eat every 2 to 3 hr is recommended. This can help maintain blood glucose levels and prevent hunger-induced nausea.
C: Drink warm ginger ale when nauseated is recommended. Ginger has antiemetic properties and can help soothe the stomach and reduce nausea.
E: Recommended actions is correct. The nurse should indicate which actions are recommended for the client.
D: Increase intake of high-fat foods is contraindicated. High-fat foods can delay gastric emptying and worsen nausea and vomiting. The client should eat low-fat, bland, and easy-todigest foods instead.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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