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 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.
Correct Answer is B
Explanation
Choice A: KoolAid is not an ideal choice for rehydration as it is high in sugar and may exacerbate diarrhea and dehydration.
Choice B : Gatorade is a suitable option for rehydration because it contains electrolytes (sodium, potassium, and chloride) that help replace those lost through diarrhea. It can help maintain
electrolyte balance and improve hydration.
Choice C Orange juice is not recommended during active diarrhea as it is acidic and may irritate the gastrointestinal tract, potentially worsening diarrhea.
Choice D Cola beverages are not recommended for rehydration as they contain caffeine, sugar, and carbonation, which can further contribute to dehydration.
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.