Hesi RN Fundamentals of Nursing
Hesi RN Fundamentals of Nursing ( 44 Questions)
Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?
Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.
Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.
Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.
Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.
Choice A Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.
Choice B Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.
Choice C Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.
Choice D Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.