a client develops a fecal impaction before digital removal of the mass which type of enema should the nurse give to loosen the feces
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HESI Fundamentals 2023 Quizlet

1. Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?

Correct answer: A

Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.

2. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue measuring the client's vital signs every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

Correct answer: B

Rationale: In this scenario, the nurse is facing a critical situation with a client showing signs of hemorrhagic shock. The surgeon's directive of waiting for an hour without providing immediate intervention poses a risk to the client's well-being. The nurse should prioritize the client's safety and advocate for timely and appropriate care. Notifying the nursing manager is the correct action as it activates the chain of command to ensure that the client receives the necessary care promptly. Documenting the provider's directive, consulting the risk manager, or completing an incident report are not the immediate actions needed to address the client's deteriorating condition and ensure patient safety.

3. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

4. During assessment, what is a nurse monitoring when assessing body alignment?

Correct answer: A

Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.

5. A client with asthma is prescribed a corticosteroid inhaler. Which instruction should the nurse provide to the client to prevent a common side effect of this medication?

Correct answer: B

Rationale: The correct instruction for the client using a corticosteroid inhaler to prevent a common side effect is to rinse the mouth with water after using the inhaler. Corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps reduce the risk of developing oral thrush. Choices A, C, and D are incorrect because using the inhaler only when experiencing symptoms, increasing fluid intake, or avoiding eating/drinking for 30 minutes after use are not directly related to preventing oral thrush, which is the common side effect associated with corticosteroid inhalers.

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