A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)
Confirm the client's identity by checking her wristband
Provide for the client's privacy by dosing the curtains
Asset the cent into the Sims position
Insert the tip of the enema tubing into the client's rectum
The Correct Answer is B,A,C,D
The correct sequence of steps the nurse should take to administer the enema is:
1. Provide for the client's privacy by closing the curtains.
2. Confirm the client's identity by checking her wristband.
3. Assist the client into the Sims position.
4. Insert the tip of the enema tubing into the client's rectum.
Proper infection control measures, preparing the enema solution, monitoring the flow rate, and documenting the procedure are among other important considerations that should be taken into account.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.
The other options mentioned are incorrect:
Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.
Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.
Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.
Correct Answer is ["C","D"]
Explanation
When reinforcing teaching with a client who has a duodenal ulcer and a new prescription for sucralfate, the nurse should include the following instructions:
"Take the medication on an empty stomach.": Sucralfate is most effective when taken on an empty stomach, usually 1 hour before meals and at bedtime. Taking it with food or other medications may reduce its effectiveness.
"Remain upright for 30 minutes after taking this medication.": To enhance the efficacy of sucralfate, it is important to remain upright for at least 30 minutes after taking the medication. This helps to prevent the medication from being washed away by stomach acid and allows it to form a protective coating over the ulcer.
The following statements are incorrect or not applicable:
"Stop taking this medication if you develop constipation.": Constipation is a common side effect of sucralfate. However, abruptly stopping the medication is not necessary if constipation occurs. The nurse should instruct the client to increase fluid intake, consume a high-fiber diet, and discuss any concerns with the healthcare provider. If constipation becomes severe or persists, the healthcare provider can provide further guidance on managing this side effect.
"Take an antacid at the same time you take this medication.": Sucralfate can interact with antacids and other medications, reducing its effectiveness. It is recommended to take sucralfate at least 2 hours before or after taking antacids or other medications to avoid interference with its absorption.
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