A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Place the client in the prone position.

Insert the lubricated tip 2.5 cm (1 in) into the anal canal.

Hang the solution bag 7.5 cm (3 in) above the rectum.

Raise the solution bag if the client exhibits pain during the procedure.

Encourage the client to retain the enema solution for 10 min.

Answer and Explanation

Correct Answer : E

A. Place the client in the prone position. The client should be placed in the Sims' (left lateral) position for enema administration.
B. Insert the lubricated tip 2.5 cm (1 in) into the anal canal. The lubricated tip should be inserted 7.5-10 cm (3-4 inches) into the anal canal.
C. Hang the solution bag 7.5 cm (3 in) above the rectum. The solution bag should be hung approximately 30 cm (12 inches) above the rectum.
D. Raise the solution bag if the client exhibits pain during the procedure. The solution bag should be lowered or the flow rate slowed if the client experiences pain.
E. Encourage the client to retain the enema solution for 10 min. Retaining the enema solution for a period of time enhances its effectiveness.

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Correct Answer is D

Explanation

A. A decrease in skinfold thickness: A decrease in skinfold thickness could be due to loss of subcutaneous fat, which might not be immediately concerning without other symptoms.
B. A triglyceride level of 150 mg/dL: A triglyceride level of 150 mg/dL is generally considered within normal limits.
C. A random blood glucose reading of 160 mg/dL: A random blood glucose reading of 160 mg/dL is elevated and could indicate impaired glucose tolerance, warranting further investigation.
D. A mole that is dark in color and tender: A dark, tender mole could be a sign of a potentially malignant melanoma and should be evaluated by a provider for further investigation and potential biopsy.

A. Encourage an Increased number of adults to abstain from alcohol use. B. Limit the intake of grain products for children older than 2 years. C. Increase calories from saturated fat intake for children older than 2 years. D. Advise adults to eat plant-based foods.

Correct Answer is D

Explanation

A. Encourage an increased number of adults to abstain from alcohol use. While reducing excessive alcohol consumption is a goal of Healthy People 2020, complete abstinence is not specifically a target unless it relates to specific health conditions or populations.
B. Limit the intake of grain products for children older than 2 years. Healthy People 2020 does not advocate for limiting grain products for children. Instead, it promotes a balanced diet that includes whole grains as part of healthy eating patterns.
C. Increase calories from saturated fat intake for children older than 2 years. Healthy People 2020 recommends reducing the intake of calories from saturated fats to promote heart health and prevent chronic diseases.
D. Advise adults to eat plant-based foods. This is correct. Healthy People 2020 encourages a diet rich in plant-based foods such as fruits, vegetables, and whole grains to improve health and reduce the risk of chronic diseases.

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A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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