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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

A. Hematocrit. B. Neutrophil count. C. Serum potassium and sodium levels. D. Blood pH level.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because hematocrit is a measure of the percentage of red blood cells in the blood, which can indicate anemia or polycythemia, but not infection.

Choice B Reason: This is correct because neutrophil count is a measure of the number of neutrophils, which are white blood cells that fight infection and inflammation. A high neutrophil count can indicate a bacterial infection, such as in the wound.

Choice C Reason: This is incorrect because serum potassium and sodium levels are measures of the electrolyte balance in the blood, which can indicate dehydration, fluid overload, or kidney dysfunction, but not infection.

Choice D Reason: This is incorrect because blood pH level is a measure of the acidity or alkalinity of the blood, which can indicate acidosis or alkalosis, but not infection.

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Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

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