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 C
No explanation
Correct Answer is B
Explanation
Choice A A bowel training schedule is not typically required for patients with an ileostomy, as they have a surgically created opening (stoma) for stool to pass directly out of the body.
Choice B Bowel training can be beneficial for patients with incontinence, as it involves establishing a regular toileting routine to help regain bowel control and prevent accidental bowel movements.
Choice C C. difficile is an infectious condition that affects the gastrointestinal tract, and bowel training may not be the primary intervention for this patient.
Choice D Crohn's disease is a chronic inflammatory bowel disease, and while bowel training may be helpful for some Crohn's patients, it is not the most common intervention for this condition.
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