Basic Care & Comfort 1

Questions cover the following topics: Medical Emergencies,

Changes/Abnormalities in Vital Signs, ArterialBlood Gases, Potential for 

Complications of Procedures, and Patient Positions

Q1. During assessment, the home health nurse learns that the client has a fecal

impaction.Before proceeding to manually remove the stool, what is the nurse's

PRIORITY?

Give an analgesic or sedative to make the client

comfortable.Teach family members to perform the

disimpaction process.

Advise the family to increase the client's fluid and

fiber intake.Recall that cardiac dysrhythmias are a

possibility.

A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum.

It is most often seen in people who are constipated for a long time. Treatment

of a fecal impaction includes administrating an enema to soften the stool to 

produce a bowel movement, or manually removing the impaction. With a 

lubricated glove, insert the index finger into the rectum to breakup the

hardened stool with a circular motion. Cardiac dysrhythmias and reflex

bradycardia can occur from vagal nerve stimulation

2.The nurse is educating the parents of a young child with a recent diagnosis 

of cystic fibrosis.The nurse tells the parents that the child will be at risk for

which vitamin deficiencies?

Folic acid and

biotinA, D, and K

B12, C, and E

B1 and pantothenic acid

People with cystic fibrosis have trouble absorbing fats, which means they also 

have trouble absorbing vitamins that need fat to be absorbed — A, D, E, and K.

These fat-soluble vitamins arecritical to normal growth and good nutrition. Bcomplex, C, folic acid, biotin, and pantothenic acid are water soluble and easily

absorbed.

3.A nurse working at a community health fair is administering intramuscular 

injections of influenza vaccine. Which injection technique will avoid

leakage into subcutaneous tissue?

Injection at a 45-degree

angle Massaging the 

injection site Aspiration

prior to injection

Injection by the Z-track method

The Z-track injection method avoids leakage into subcutaneous tissue. Pull the 

client's skin downward or upward, and inject the vaccination (or medication) at

a 90-degree angle beforereleasing the skin. Aspiration is done to assure that the

injection is not going into a vein or artery.Massaging the injection site can 

introduce the material into subcutaneous tissue. A 45-degree angle is incorrect.