While the nurse is removing a fecal impaction, the client begins to perspire profusely and complains of shortness of breath. The nurse notes that the client's pulse rate has slowed to 44 beats per minute. Which is the priority action by the nurse?
1. Holding the fingers still until the symptoms stop, and then resuming removal of fecal impaction
2. Stopping the procedure immediately
3. Continuing the procedure, and monitoring the client carefully
4. Stopping the procedure and calling the health care provider immediately
2
Rationale 1Holding the fingers still and then resuming the procedure is likely to result in arrhythmias and worsening symptoms.
Rationale 2: The client is demonstrating signs of vagal nerve stimulation, so the nurse should stop the procedure immediately and monitor the client for easing of symptoms.
Rationale 3: Continuing the procedure is likely to result in arrhythmias and worsening symptoms.
Rationale 4: If symptoms do not resolve within a few minutes, the nurse might need to notify the health care provider, but discontinuation of stimulation is usually the only treatment required.
Global Rationale: The client is demonstrating signs of vagal nerve stimulation, so the nurse should stop the procedure immediately and monitor the client for easing of symptoms. If symptoms do not resolve within a few minutes, the nurse might need to notify the health care provider, but discontinuation of stimulation is usually the only treatment required. Holding the fingers still and then resuming the procedure, or continuing the procedure, is likely to result in arrhythmias and worsening symptoms.
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