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 C
Explanation
Choice A rationale:
“Reflection is thinking about what I did and how I can improve.” Rationale: Reflection involves self-assessment and critical thinking about past actions to identify areas for improvement. This statement correctly defines reflection and does not indicate a need for further teaching.
Choice B rationale:
“Analysis is breaking down a complex situation into smaller parts.” Rationale: Analysis is the process of examining complex situations by breaking them down into smaller, manageable components for a more in-depth understanding. This statement accurately describes analysis and does not indicate a need for further teaching.
Choice C rationale:
“Inference is making assumptions based on my experience.” Rationale: Inference involves drawing conclusions or making predictions based on available evidence rather than personal experience. This statement incorrectly defines inference, indicating a need for further teaching.
Choice D rationale:
“Evaluation is checking the reliability and validity of information.” Rationale: Evaluation refers to the process of assessing the credibility, accuracy, and relevance of information or data. This statement accurately defines evaluation and does not indicate a need for further teaching.
Correct Answer is B
Explanation
The correct answer is choice b. “Curling’s ulcer.”
Choice A rationale:
Elevated blood pressure is not a common complication specifically associated with partial-thickness burns. It may occur due to pain or stress but is not the most critical complication to anticipate.
Choice B rationale:
Curling’s ulcer, a type of stress ulcer, is a significant complication that can develop in burn patients due to the stress response and reduced blood flow to the gastrointestinal tract.
Choice C rationale:
Compartment syndrome is more commonly associated with circumferential full-thickness burns rather than partial-thickness burns.
Choice D rationale:
Excruciating pain is a symptom rather than a complication. While pain management is crucial, it is not the most critical complication to anticipate.
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