A patient requires digital removal of a fecal impaction. Which action should the nurse perform before beginning this procedure?
a. Administer large-volume tap water enemas until clear.
b. Assist the patient into the dorsal recum-bent position.
c. Check for an order from the healthcare provider.
d. Delegate the procedure to nursing assistive personnel (NAP).
C
The nurse obtains an order from the healthcare provider before implementing fecal impaction removal because it is an invasive procedure and can precipitate unexpected results such as bra-dycardia. The nurse wants the provider's validation of the procedure to provide safe and effec-tive nursing care. Other strategies to stimulate a bowel movement, such as suppositories and enemas, will be tried before determining that digital removal of a fecal impaction is needed. For fecal impaction removal, the nurse assists the patient to the side-lying position. The nurse cannot delegate the procedure to the NAP because it requires the clinical judgment and critical thinking skills of a nurse.
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