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A nurse is caring for an elderly client experiencing gastrointestinal discomfort.

Exhibits
Select the appropiate client instructions for the administration of enemas

A.

Retain the fluid for a few minutes before expelling

B.

Be aware of potential electrolyte imbalances

C.

Avoid using enemas frequently

D.

Understand the benefits of different solutions

E.

Follow provider instructions on enema type and solution

F.

Increase intake of fluids to aid bowel movement

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

Rationale:
A. The pH of 7.3 indicates acidemia (normal range 7.35–7.45). The PaCO2 of 50 mm Hg is elevated (normal 35–45 mm Hg), indicating a respiratory cause. This combination is consistent with respiratory acidosis.
B. Respiratory alkalosis would present with a high pH and low PaCO2.
C. Metabolic acidosis would show a low pH and low HCO3-.
D. Metabolic alkalosis would show a high pH and elevated HCO3-.

Correct Answer is ["D","E","F"]

Explanation

Rationale:

  • Improved breathing indicates that the removal of ascitic fluid has relieved diaphragmatic pressure, allowing better lung expansion.
  • Decreased abdominal pressure demonstrates that fluid removal has reduced intra-abdominal tension, improving mobility and comfort.
  • Relief of abdominal discomfort is a primary goal of paracentesis, as it enhances quality of life and reduces pain caused by fluid accumulation.
  • Stable vital signs and absence of respiratory distress are important for monitoring safety but are not direct measures of the procedure’s effectiveness.
  • Reduced ascitic fluid volume is the mechanism of action of paracentesis, while the client’s symptomatic relief is the best indicator of clinical success.

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