The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action?
a. Preparing the patient for a second tap water enema
b. Obtaining an order for digital removal of stool
c. Positioning the patient on the left side
d. Inserting a rectal tube
ANS: B
When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be applicable or effective for this patient.
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