The nurse prepares to exercise a digital removal of feces. To ...

[HudsonKB16]

The nurse prepares to exercise a digital removal of feces. To detect an untoward effect of this procedure, the nurse should assess the patient history for which condition?
 
  a. Heart disease
  b. Abdominal pain
  c. Urinary infection
  d. Diabetes mellitus

Question 2

A client receiving gastrostomy feedings develops diarrhea. The nurse should:
 
  A. Aspirate stomach contents
  B. Discontinue the feedings
  C. Maintain the client in a side-lying position
  D. Review the client's medications and type of formula

[hollysheppard095]

Answer to Question 1

A
Because of the potential to stimulate the vagus nerve, patients with a history of dysrhythmia or heart disease are at greater risk for changes in heart rhythm. Be sure to monitor the patient's pulse before and during the procedure. This procedure may be contraindicated in cardiac patients; if in doubt, verify with the physician. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (around the impacted stool), and urinary frequency. Abdominal pain by itself is not indicative of the need for extra caution. Symptoms of fecal impaction include urinary frequency, not infection. There is no correlation between the two.

Answer to Question 2

D
D. Determine if client is receiving antibiotics or medications (e.g., those containing sorbitol), which can induce diarrhea. Notify physician and confer with dietitian to determine need to modify type of formula, concentration, or rate of infusion.
A. Stomach contents are aspirated to determine tube placement.
B. Excessive gastric residual volumeNotify physician to determine if feedings need to be held. If feedings are held, reassess residual volume 1 hour after the feeding is stopped to determine if volume has lessened or increased.
C. Position the client on side to protect the airway.

[HudsonKB16]

TYSM

[Joy Chen]

Excellent