A client is prescribed a cleansing enema. Prior to administering the enema, the client should be told to:

drink a full glass of water.

hold the solution for a couple of minutes.

take fast breaths through the nose.

lie on the left side with the right knee bent

Answer and Explanation

The Correct Answer is D

D. Before administering a cleansing enema, the client is typically instructed to assume a left-side lying position with the right knee bent. This position helps to facilitate the flow of the enema solution into the colon and allows for better retention of the solution. It also helps to prevent leakage and discomfort during the procedure.

A. Drinking water before administering an enema can help hydrate the client and promote normal bowel function. However, it is not typically a specific instruction related to the administration of the enema itself. Hydration is generally beneficial for bowel health but is not directly related to the enema procedure.

B. After administering the enema solution, the client should be instructed to hold the solution in the bowel for a sufficient amount of time to allow it to soften and loosen stool. The exact duration can vary based on the type and purpose of the enema, but typically, the client is encouraged to retain the solution for a specified period (as instructed by the healthcare provider) before evacuating.

C. This instruction is unrelated to the administration of a cleansing enema. Breathing techniques may be taught for relaxation or to manage discomfort during procedures, but they do not specifically apply to the process of administering an enema.

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Correct Answer is C

Explanation

C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.

A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.

B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.

D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.

A. listens as the client describes the day she was diagnosed with breast cancer. B. compliments the client when he correctly places an ostomy bag on his stoma. C. provides a bed bath with a back rub to help the client relax. D. maintains eye contact with the client throughout their conversation.

Correct Answer is A

Explanation

A. By actively listening, the nurse shows empathy and a willingness to understand the client's perspective. Understanding significant events like a cancer diagnosis can help the nurse better anticipate the client's emotional and psychological needs.

B. This action shows support and encouragement for the client's achievements in managing their condition. It demonstrates the nurse's awareness of the client's efforts and competence in self-care. While it is positive reinforcement and supportive, it focuses more on the client's physical abilities rather than a deeper understanding of their personal experiences or emotions.

C. This action shows attentiveness to the client's physical comfort and emotional well-being. Offering a back rub during a bed bath can be soothing and comforting, addressing both physical and emotional needs. It demonstrates a caring approach to providing care that considers the client's comfort and relaxation.

D. Eye contact is an important non-verbal communication skill that conveys attentiveness and respect. It helps establish a connection and rapport between the nurse and the client. While maintaining eye contact is important for effective communication and building trust, it alone does not necessarily illustrate knowing the client in terms of understanding their personal experiences or emotions.

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A client is prescribed a cleansing enema. Prior to administering the enema, the client should be told to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:

Correct Answer is C

Explanation

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

Correct Answer is A

Explanation

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A client is prescribed a cleansing enema. Prior to administering the enema, the client should be told to:

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