Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?
Abdominal girth.
Breath sounds.
Bowel sounds.
Vital signs.
The Correct Answer is D
Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.
This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.
These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.
Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D
This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
Choice A is not the correct answer because it assumes that the client is feeling lonely without giving them the opportunity to express their own feelings.
Choice B is not the correct answer because it confronts the client about their behavior in an accusatory manner.
Choice C is not the correct answer because it suggests a solution without first exploring the client’s feelings and needs.
Correct Answer is A
Explanation
Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.
In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”
Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.
Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.
Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.
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