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 ["A","B","C"]
Explanation
Rationale:
A. Decompensated cirrhosis impairs the liver’s ability to process bilirubin, leading to yellowing of the skin and eyes.
B. Accumulation of ammonia and other toxins due to liver dysfunction can cause confusion, altered level of consciousness, and asterixis.
C. Fluid shifts into the peritoneal cavity occur due to low albumin levels and portal hypertension, causing abdominal distention.
D. While beneficial for overall health, exercise is not a clinical manifestation of cirrhosis.
Correct Answer is ["A","C","E"]
Explanation
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.
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