The nurse performs digital removal of feces for a client. Which client diagnosis cues the nurse to assess the client more frequently than usual during the procedure?
1. Abdominal pain
2. Atrial fibrillation
3. Urinary infection
4. Diabetes mellitus
2
2. The nurse assesses the client who has atrial fibrillation more frequently during dig-ital removal of a fecal impaction because the client has a serious cardiac arrhythmia. Although most clients with atrial fibrillation have ventricular response rates greater than 100 beats/min, most also have heart disease. The nurse scrutinizes the client keenly during the procedure, taking frequent blood pressures and heart rates, because impaction removal can cause a vasovagal response and slow the heart rate. The client with heart disease is more likely to be unable to compensate for the changing heart rate.
1. The fecal impaction is a likely cause of the abdominal pain; however, a client with abdominal pain is assessed thoroughly before the procedure to ensure the client is suitable for impaction removal.
3. Urinary infection should not contraindicate impaction removal or cause difficulty during the procedure.
4. The client with diabetes mellitus is assessed before the procedure to avoid a gly-cemic crisis during the impaction removal.
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