When evaluating a client’s rectal bleeding, which findings should the nurse document?

Number of blood clots expelled with each stool.

Unique odor noted with gastrointestinal bleeding.

Color characteristics of each stool.

Evidence of internal hemorrhoids.

Answer and Explanation

The Correct Answer is C

A. Number of blood clots expelled with each stool. This is not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding. While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool. Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids. While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Tenderness upon palpation of the thoracic region is an abnormal finding and may indicate inflammation, infection, or other pathological conditions.
Choice B rationale
A thrill is a palpable vibration over the chest wall, often associated with turbulent blood flow due to cardiac abnormalities. It is not a normal finding in the thoracic region.
Choice C rationale
Non-tenderness upon palpation of the thoracic region is a normal finding, indicating the absence of inflammation, infection, or other abnormalities.
Choice D rationale
Crepitus is a crackling or popping sensation felt under the skin, often due to the presence of air in the subcutaneous tissue. It is not a normal finding and may indicate conditions such as pneumothorax or subcutaneous emphysema.

A. Apply warm blankets to both feet. B. Notify the healthcare provider. C. Use a doppler ultrasonic stethoscope. D. Palpate pulse points with legs dependent.

Correct Answer is C

Explanation

Choice A rationale
Applying warm blankets to both feet is not the appropriate action when unable to palpate pedal pulses. This action does not address the underlying issue of assessing blood flow.
Choice B rationale
Notifying the healthcare provider is premature without first attempting to locate the pulses using a Doppler ultrasonic stethoscope.
Choice C rationale
Using a Doppler ultrasonic stethoscope is the correct action. This device helps detect and amplify blood flow, allowing the nurse to assess the pulses even if they cannot be palpated manually.
Choice D rationale
Palpating pulse points with legs dependent is not the most effective method to locate non- palpable pulses. Using a Doppler ultrasonic stethoscope is more reliable.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When evaluating a client’s rectal bleeding, which findings should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

Correct Answer is C

Explanation

When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen.Which action should the nurse take in response to this observation?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

While completing an admission assessment, the nurse is unable to palpate the client’s left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?