A nurse is caring for an adolescent.
Admission Assessment
1400:

• Adolescent brought to emergency department by parents following a fall while skateboarding.
• Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.
• Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.
• Abdomen soft and nontender with active bowel sounds in all four quadrants.
• Right lower extremity with open wound and displaced bone.
• Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.

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.