A nurse is caring for an elderly client experiencing gastrointestinal discomfort.
Retain the fluid for a few minutes before expelling
Be aware of potential electrolyte imbalances
Avoid using enemas frequently
Understand the benefits of different solutions
Follow provider instructions on enema type and solution
Increase intake of fluids to aid bowel movement
Correct Answer : A,C,E
Rationale:
- Retaining the fluid allows the enema to soften stool and stimulate peristalsis effectively.
- Avoiding frequent use prevents dependence and irritation of the bowel.
- Following provider instructions ensures safe and appropriate selection of enema type and solution for the client’s condition.
- Electrolyte imbalances, benefits of solutions, and fluid intake are important considerations but are broader teaching points, not immediate enema administration instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Rationale:
A. The client should not infuse dextrose solution independently if TPN runs out; this could cause serious metabolic complications.
B. TPN should not be stopped abruptly once weight gain is achieved; discontinuation should be gradual to prevent hypoglycemia.
C. Maintaining the prescribed infusion rate is important to ensure proper nutrient delivery and prevent metabolic complications.
D. TPN should never be shaken if a precipitate is present; this can cause embolism or catheter occlusion.
E. TPN should be refrigerated when not in use to prevent bacterial contamination and preserve solution stability.
Correct Answer is B
Explanation
Rationale:
A. Lifting restrictions are typically advised for 2–4 weeks after laparoscopic cholecystectomy, not immediately postoperatively.
B. Encouraging ambulation once the client is fully awake helps prevent complications such as atelectasis, deep vein thrombosis, and promotes bowel function.
C. Placing the client flat in a supine position can increase the risk of respiratory complications; semi-Fowler’s is preferred.
D. Offering ice cream is not appropriate immediately after surgery; clear liquids are usually initiated first to assess tolerance.
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