During a fecal impaction removal, an older client complains of feeling dizzy and cold.
Which intervention should the nurse implement?
Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back.
Insert a gloved finger into the rectum and gently massage the rectal sphincter.
Stop the procedure and observe for a reduction in symptoms before continuing.
Encourage the client to take slow, deep breaths while continuing the procedure.
Encourage the client to take slow, deep breaths while continuing the procedure.
The Correct Answer is A
Choice A rationale:
Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.
Choice B rationale:
Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.
Choice C rationale:
Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.
Choice D rationale:
Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Aspirin is not typically contraindicated in a client who has taken sildenafil unless there are specific contraindications or allergies. Aspirin is often used in the management of acute chest pain to help prevent blood clot formation.
Choice B rationale:
Heparin is not contraindicated solely because the client has taken sildenafil. Heparin is an anticoagulant commonly used in various clinical settings, including the management of certain cardiac conditions.
Choice C rationale:
Morphine is not necessarily contraindicated based solely on the client's use of sildenafil. Morphine can be used to relieve chest pain in some cases of acute coronary syndrome. However, its use should be carefully evaluated based on the client's overall clinical presentation.
Choice D rationale:
Nitroglycerin should be withheld in this scenario. Sildenafil is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. It can potentiate the vasodilatory effects of nitroglycerin, leading to a severe drop in blood pressure. Concomitant use of nitroglycerin and sildenafil is contraindicated due to the risk of significant hypotension, which can be life-threatening.
Correct Answer is A
Explanation
Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.
Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.
Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.
Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.
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