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
ChoiceA: This volume might be insufficient for a large volume, cleansing enema, as it may not effectively cleanse the colon.
Choice: This range is the appropriate volume for a large volume, cleansing enema, as it provides enough fluid to cleanse the colon effectively without causing excessive distension.
Choice C: This volume is too low for a large volume, cleansing enema, and it may not be enough to achieve the desired effect.
Choice D: This volume is too low for a large volume, cleansing enema, and it may not effectively cleanse the colon.
Correct Answer is D
Explanation
Choice A Depending on laxatives or stool softeners every day may lead to dependence and can be harmful in the long term. It is not a preferred approach for managing constipation.
Choice B While eating smaller, more frequent meals can aid digestion, it is not the primary strategy for preventing constipation.
Choice C : Increasing dietary fiber intake is an effective way to promote regular bowel
movements and prevent constipation. Gradually increasing fiber intake helps the body adjust to the increased fiber load.
Choice D Adequate fluid intake is important for bowel health, but focusing solely on fluid intake may not be as effective as increasing dietary fiber to prevent constipation.
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