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

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

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 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?

Correct Answer is D

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

How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

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

Which response by the nurse is most therapeutic?

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?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?