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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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Elevating the head of the bed to a semi-Fowler's or high Fowler's position helps prevent aspiration during the feeding. This position facilitates proper digestion and reduces the risk of

regurgitation or reflux. It allows gravity to assist in keeping the feeding in the stomach and reduces the likelihood of complications.

The other actions mentioned are also important steps in the process but should be performed after elevating the head of the bed:

Measure stomach contents: This step is usually done before administering any enteral feeding to check for the presence of residual gastric contents. It helps determine if the client is tolerating previous feedings and guides adjustments in the feeding volume or rate if needed.

Return gastric content into the gastrostomy tube: If there is a significant amount of gastric residual, it is recommended to return the contents into the stomach before administering the feeding. This helps ensure that the client receives the full prescribed amount of the enteral feeding.

Flush the tube with water: Flushing the gastrostomy tube with water before and after the feeding helps maintain tube patency, clears any residual feeding or medication, and prevents clogging.

A. Expect breast tenderness while taking this medication, B. Wait at least 1 hr after taking the medication before taking an antacid C. Take ibuprofen for occasional aches and pains D. Take this medication on an empty stomach

Correct Answer is B

Explanation

When reinforcing teaching about cimetidine with a client who has peptic ulcer disease, the nurse should include the following information:

"Wait at least 1 hour after taking the medication before taking an antacid.": Cimetidine is a histamine-2 receptor antagonist that reduces stomach acid production. Taking an antacid too close in time to cimetidine may decrease its effectiveness as antacids can interfere with its absorption. The nurse should advise the client to follow the healthcare provider's instructions regarding the timing and administration of cimetidine and antacids.

The following statements are incorrect or not applicable:

"Expect breast tenderness while taking this medication.": Breast tenderness is not a common side effect of cimetidine. If the client experiences any unusual symptoms or side effects while taking the medication, they should consult their healthcare provider for further evaluation.

"Take this medication on an empty stomach.": To reduce stomach upset, this medication should be taken with food or milk

"Take ibuprofen for occasional aches and pains.": Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal complications, including ulcers. In individuals with peptic ulcer disease, it is generally recommended to avoid NSAIDs unless specifically prescribed by a healthcare provider. The nurse should emphasize the importance of discussing any pain management strategies or medications with the healthcare provider before use.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about cimetidine with a client who has peptic ulcer disease. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is checking the client's bowel sounds. At which time should the nurse auscultate the client's abdomen?

A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 ml. How many ml. should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?