The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should:
a. Flex the finger, and slowly insert it toward the umbilicus.
b. First instruct the patient that this procedure will be painful.
c. Insert an extended index finger at a right angle to the anus.
d. Place the finger directly into the anus to overcome the tight sphincter.
ANS: A
The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.
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