Question

the nurse is caring for a client with a tentative diagnosis of intussusception. the client had diarrhea before admission but while waiting for administration of the enema to reduce the intussusception, the client passes a normal brown stool. which nursing action is the most appropriate?

Answer 1

Notify the practitioner if the nursing action is the best option for  intussusception.

The passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.

PTS: 1 DIF: Cognitive Level: Apply REF: 809

TOP: Integrated Process: Nursing Process: Implementation

MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential.

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The question is -

The nurse is caring for a boy with probable intussusception. He had diarrhea before admission but, while waiting for the administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?

a. Notify the practitioner.

b. Measure abdominal girth.

c. Auscultate for bowel sounds.

d. Take vital signs, including blood pressure.