A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction?
A) Inserted a lubricated, gloved finger into the rectum.
B) Facilitate a barium enema.
C) Insert a lubricated rectal tube into the rectum.
D) Administer an oil retention enema into the rectum.
A
Feedback:
The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a barium enema is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.
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