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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.

A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.

Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.

Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.

Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.

A. Determine how the client feels. B. Support the client when rising. C. Offer a pair of non-skid socks. D. Place the chair by the bed.

Correct Answer is A

Explanation

After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.

This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.

Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.

Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.

Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.

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Prior to performing digital removal of a fecal impaction, what is the most important assessment for the nurse to perform?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care. What is the next approach for the nurse to use when discussing end of life issues with the client?

Correct Answer is C

Explanation

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

Correct Answer is A

Explanation

Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?

An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?