A nurse is digitally removing stool that is impacted from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:
Blood pressure increases from 110/84 to 118/88 mm Hg.
Temperature increases from 98.8°F to 99.0°F.
Pulse rate decreases from 78 to 52 beats/min.
Respiratory rate increases from 16 to 24 breaths/min.
The Correct Answer is C
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Bright red stool can be caused by various factors, including the consumption of certain foods, medications, or gastrointestinal bleeding. Stress can lead to changes in bowel movements and might cause bright red stool due to increased gastrointestinal motility.
Choice B: While it's essential to reassure the patient, dismissing their concern without further assessment is not appropriate. The nurse should still investigate the potential causes of bright red stool.
Choice C: Jumping to conclusions and ordering immediate tests without further assessment is not the best approach. Before taking any action, the nurse should gather more information and assess other possible causes.
Choice D: Suggesting a colonoscopy as the first step is not necessary for every case of bright red stool. Further assessment is needed to determine the cause before resorting to such an invasive procedure.
Correct Answer is D
Explanation
Choice A Alcohol swabs may be too harsh and irritating for the delicate skin around the stoma. Mild soap and water are preferred for cleaning.
Choice B Tap water alone may not be sufficient for removing debris and ensuring proper cleanliness around the stoma. Mild soap and water are preferred for cleaning.
Choice C Iodine may be too harsh and irritating for the peristomal skin. Mild soap and water are preferred for cleaning.
Choice D Mild soap and water are the best choice for cleaning around the colostomy stoma as they effectively remove debris and cleanse the area without being overly harsh on the skin.
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