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 B
Explanation
Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.
The other tasks mentioned should not be delegated to an AP:
Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.
Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.
Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires
specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.
Correct Answer is ["100"]
Explanation
To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula: Flow rate (gtt/min) = (Volume to be infused in mL) x (Drop factor) / (Time in minutes) In this case, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.
Flow rate (gtt/min) = (100 mL) x (60 gtt/mL) / (60 min)
Canceling out the mL and min units, the formula becomes:
Flow rate (gtt/min) = 100 x 60 / 60
Flow rate (gtt/min) = 100
Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.
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