Question

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

a. Use a warm water enema to soften the stool first.
b. Administer a mineral oil enema to lubricate the rectum.
c. Insert a gloved finger into the rectum and gently break up the stool.
d. Encourage the client to bear down and push the stool out.

Answer 1

The nurse should choose option c, which is to insert a gloved finger into the rectum and gently break up the stool when digitally evacuating it. This method helps to soften and dislodge the impacted feces.

Step-by-step explanation:

The nurse should take option c, which is to insert a gloved finger into the rectum and gently break up the stool when digitally evacuating it.

This manual removal method, also known as digital disimpaction, is often performed as a last resort when other interventions have failed to relieve fecal impaction.

Gently breaking up the stool with a gloved finger helps to soften and dislodge the impacted feces, making it easier to remove.