The nurse exercises caution during the digital removal of feces ...

[cagreen833]

The nurse exercises caution during the digital removal of feces for a client with:
 
  A. Heart disease
  B. Abdominal pain
  C. Urinary infection
  D. Diabetes mellitus

Question 2

A nurse suspects that the intraspinal catheter has punctured the dura when:
 
  A. Clear drainage is noted
  B. Bloody drainage is noted
  C. Purulent drainage is noted
  D. Redness, warmth, and swelling are noted

[Brenm]

Answer to Question 1

A
A. Because of the potential to stimulate the sacral branch of the vagus nerve, clients with a history of dysrhythmia or heart disease have a greater risk of changes in heart rhythm. Be sure to monitor client's pulse before and during procedure. This procedure may be contraindicated in cardiac clients; if in doubt, verify with physician.
B. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency.
C. Symptoms of fecal impaction include urinary frequency, not infection.
D. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency, not diabetes mellitus.

Answer to Question 2

A
A. Clear drainage may indicate puncture of dura.
B. Bloody drainage may indicate catheter entered blood vessel.
C. Purulent drainage is sign of infection.
D. Local inflammation and superficial skin infection at insertion site can occur.

[cagreen833]

Excellent

[mjenn52]

Gracias!