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 D
Explanation
Choice A Laxatives might be an option, but they should not be the first intervention. Other noninvasive measures should be tried first.
Choice B Administering a cleansing enema is not the first intervention for a patient having
trouble defecating into a bedpan. It is an invasive procedure and should be considered after less invasive measures have been tried.
Choice C Withholding pain medication might lead to unnecessary discomfort for the patient and is not the best approach to promote bowel movements.
Choice D Raising the head of the bed will help the patient assume a more upright position, which can facilitate bowel movement and defecation into the bedpan more effectively.
Correct Answer is B
Explanation
The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Choice A rationale:
Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.
Choice B rationale:
Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.
Choice C rationale:
Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.
Choice D rationale:
Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.
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