A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

cool the solution to 65 degrees F

boil the solution and let it cool down.

warm the solution to body temperature

warm the solution in the microwave.

Answer and Explanation

The Correct Answer is C

Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.

Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.

Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.

Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.

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Correct Answer is C

Explanation

Choice A For an ileostomy, liquid consistency of stool is expected as the output, and it is not an immediate concern.

Choice B Foul odor from the stool is common with ileostomy output, and while it can be unpleasant, it is not an immediate concern.

Choice C This finding should be reported immediately, as it could indicate bleeding from the stoma or intestinal mucosa, which requires prompt evaluation and intervention.

Choice D Continuous output from an ileostomy is normal and expected, so it is not a cause for immediate concern.

A. Cause of the patient's anxiety and fear. B. Patient's bowel sounds and presence of gas. C. Family's questions about the procedure. D. Patient's lung sounds and respiratory rate.

Correct Answer is A

Explanation

Choice A Addressing the cause of the patient's anxiety and fear is the priority to provide

emotional support and comfort. The nurse should actively listen to the patient's concerns and offer appropriate reassurance and information.

Choice B While assessing the patient's bowel sounds and gas is important for the overall care, it is not the priority at this moment when the patient is expressing fear and anxiety.

Choice C Addressing the family's questions is important, but the patient's emotional wellbeing should be the immediate focus.

Choice D Respiratory assessment is essential but is not the priority when the patient is expressing fear and anxiety about the upcoming surgery.

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A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

Correct Answer is C

Explanation

The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." It is a priority for the nurse to focus on addressing the

Correct Answer is A

Explanation

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A nurse is caring for 4 patients each patient has a colostomy bag. Which patient should be seen first and made a priority?

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