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 The supine position (lying flat on the back) is not suitable for administering an enema as it does not facilitate proper flow and retention of the solution.
Choice B High Fowler's position (sitting upright at a 90degree angle) is not appropriate for enema administration, as it might cause discomfort and hinder proper administration.
Choice C Semi Fowler's position (sitting at a semiupright angle) is also not the best option for enema administration, as it may not allow the solution to flow effectively.
Choice D The Sims position, with the patient lying on the left side with the right knee flexed, allows the enema solution to flow downward by gravity and improves retention. It is the best position for enema administration.
Correct Answer is B
Explanation
Choice A Pneumonia is not a contraindication for a tap water enema.
Choice B A tap water enema is not recommended for patients with edema or excess fluid volume due to the risk of further fluid overload.
Choice C Hypertension is not a contraindication for a tap water enema unless the patient has other cardiovascular conditions that could be exacerbated by the procedure.
Choice D Diabetes mellitus is not a contraindication for a tap water enema. However, patients with diabetes may need careful monitoring during the procedure due to potential glucose
fluctuations.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.