Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?
Abdominal girth.
Bowel sounds.
Vital signs.
Breath sounds.
The Correct Answer is C
Choice A Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.
Choice B Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.
Choice C Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.
Choice D Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low. It’s important to first ensure the accuracy of the reading before escalating oxygen delivery methods.
Choice B reason: Removing the nasal cannula is not advisable. The patient is postoperative and may have impaired gas exchange due to anesthesia, pain, or decreased mobility. Removing the supplemental oxygen may worsen the patient’s hypoxemia and increase the risk of complications.
Choice C reason: Increasing the oxygen to 3 L/minute could be a potential action if the oxygen saturation reading is accurate and the patient’s condition does not improve. However, any changes to a patient’s oxygen therapy should be made under the guidance of a healthcare provider. It’s important to first verify the accuracy of the oxygen saturation reading.
Choice D reason: Verifying the placement of the pulse oximeter is the highest priority action. Before making changes to the oxygen flow rate, it’s important to ensure that the oxygen saturation reading is accurate. Incorrect placement or function of the pulse oximeter could lead to inaccurate readings.
Correct Answer is D
Explanation
Choice A: Massage the injection site to increase absorption is not a correct instruction because it may cause bruising and bleeding. Low-molecular-weight heparin is absorbed quickly without massaging.
Choice B: Rotate injections between the abdomen and gluteal areas is not a correct instruction because it may increase the risk of hematoma and infection. The abdomen is preferred over other sites for low-molecular-weight heparin injections.
Choice C: Expel the air in the prefilled syringe prior to injection is not a correct instruction because it may result in loss of medication and inaccurate dosing. The air bubble in the prefilled syringe should be left intact.
Choice D: Inject in abdominal area at least 2 inches from the umbilicus is a correct instruction because it ensures adequate subcutaneous tissue and avoids major blood vessels and organs.
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