What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

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Question 1 of 5

What finding of the nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

Correct Answer: B

Rationale: Oozing liquid stool indicates probable fecal impaction in a paralyzed client. Immobility slows peristalsis, hardening stool; liquid seeps around the blockage, a classic sign. Blood suggests trauma, not impaction. Flatulence reflects gas, not obstruction. Absent bowel movements are expected in paralysis but nonspecific. B aligns with impaction pathophysiology, requiring intervention like disimpaction, making it the key finding.

Question 2 of 5

A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?

Correct Answer: D

Rationale: An RN should be assigned an unresponsive client post-MVA. Complex needs (e.g., neuro checks) exceed UAP , student , or PN scope. RN expertise ensures safety during transfer, making D the best assignment.

Question 3 of 5

During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?

Correct Answer: B

Rationale: Reviewing the skills checklist best assesses competence. It objectively verifies abilities post-orientation, unlike supervision needs , comfort , or preferences . B ensures safe assignment, making it the top approach.

Question 4 of 5

A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?

Correct Answer: A

Rationale: Explaining dentures must come out is most appropriate. They risk aspiration or damage during anesthesia, per safety protocols. Second thoughts assume unrelated issues. Notification or OR removal delay resolution. A ensures compliance, making it the best intervention.

Question 5 of 5

When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?

Correct Answer: B

Rationale: Deep breathing is best for stress management 1 hour pre-surgery. It's simple, immediate, and reduces anxiety via parasympathetic activation, fitting time constraints. Biofeedback needs equipment, distraction varies, imagery requires practice. B aligns with pre-op needs, making it the top technique.

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