The client requires digital removal of a fecal impaction. Which should the nurse implement?
1. Administer a large-volume tap water enema.
2. Assist client to the dorsal recumbent position.
3. Consult with provider to implement procedure.
4. Delegate the procedure to the nursing assistant.
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3. The nurse obtains the provider's prescription before implementing fecal impaction removal because it is an invasive procedure and can precipitate unexpected results such as bradycardia. The nurse wants the provider's validation of the procedure to provide safe and effective nursing care.
1. If the nurse determines that the client needs fecal impaction removal, the nurse has tried other strategies to stimulate a client bowel movement, including suppositories and enemas.
2. For fecal impaction removal, the nurse assists the client to the side-lying position.
4. The nurse cannot delegate the procedure to the nursing assistant because the pro-cedure requires the clinical judgment and critical thinking skills of a nurse.
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