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 D

Explanation

Neutrophils are a type of white blood cell that play a key role in fighting infections.

An elevated neutrophil count can indicate the presence of an infection.

Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client’s neutrophil count.

Choice A is not correct because hematocrit is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.

Choice B is not correct because serum is not a laboratory value.

Choice C is not correct because blood PT level is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.a

A. Inject in abdominal area at least 2 inches from the umbilicus. B. Rotate injections between the abdomen and gluteal areas. C. Massage the injection site to increase absorption. D. Expel the air in the prefilled syringe prior to injection.

Correct Answer is A

Explanation

Inject in abdominal area at least 2 inches from the umbilicus.

When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh.

Your tummy is usually best as the injection site and it is important that you change the site each time 1.

The heparin needs to go into the fat layer under the skin 2.

Choice B is incorrect because injections should not be rotated between the abdomen and gluteal areas.

Choice C is incorrect because massaging the injection site is not recommended.

Choice D is incorrect because air bubbles in a pre-filled syringe should not be expelled prior to injection 2.

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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

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 D

Explanation

The nurse is teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

Correct Answer is A

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. What should the nurse direct the client's attention on during the session?

An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain. To assess the intensity of the client's pain, which approach should the nurse use?

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

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?

An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?