Author Question: While the nurse is removing a fecal impaction, the client begins to perspire profusely and complains ... (Read 80 times)

misspop · **on:** Jun 25, 2018

While the nurse is removing a fecal impaction, the client begins to perspire profusely and complains of shortness of breath. The nurse notes that the client's pulse rate has slowed to 44 beats per minute. Which is the priority action by the nurse?

1. Holding the fingers still until the symptoms stop, and then resuming removal of fecal impaction
2. Stopping the procedure immediately
3. Continuing the procedure, and monitoring the client carefully
4. Stopping the procedure and calling the health care provider immediately

Question 2

The nurse is caring for an older adult client with an ileostomy and hemiplegia secondary to a stroke experienced a few years ago. When changing the client's one-piece appliance, the nurse finds the skin under the skin barrier is ulcerated and erythematous

The client does not empty the pouch until it is completely full because it hurts so much to remove the skin barrier. Which action by the nurse is the priority?

1. Apply a two-piece ostomy appliance.
2. Treat the damaged skin and replace the one-piece pouch.
3. Keep the skin open to air to allow time for healing, and replace the ostomy appliance in a few days.
4. Call the health care provider to report the damaged skin.

cupcake16 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2

The client is demonstrating signs of vagal nerve stimulation, so the nurse should stop the procedure immediately and monitor the client for easing of symptoms. If symptoms do not resolve within a few minutes, the nurse might need to notify the health care provider, but discontinuation of stimulation is usually the only treatment required. Holding the fingers still and then resuming the procedure, or continuing the procedure, is likely to result in arrhythmias and worsening symptoms.

Answer to Question 2

Correct Answer: 1

The client who requires emptying of the pouch one or more times per day will benefit from a drainable pouch. However, when the client lacks dexterity, he will benefit from a drainable two-piece pouch, allowing the pouch to be removed to empty, instead of a drainable pouch. A one-piece pouch needing to be changed daily requires the client to remove both the pouch and the skin barrier, which could be the cause of the trauma. Allowing the pouch to fill completely before changing can lead to leakage, which will also contribute to the skin damage. Because the client has an ileostomy, leaving the appliance off is not an option, because the ostomy will drain continuously. There is no need to call the health care provider, because the nurse can provide skin care without an order.