A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Hold the container of solution 30 cm (12 in) above the anus.

Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.

Hold the container of solution level with the client's upper hip.

Keep the container of solution at a level to maintain client comfort.

Answer and Explanation

The Correct Answer is A

A.   This is the appropriate height to allow the fluid flow by gravity.
B.   This is such a short distance and the fluid wouldn't flow as desired.
C.   Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D.   This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

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Correct Answer is ["A","B","C"]

Explanation

A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.

A. Obtain the provider's signature within 8 hr. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record. D. Implement a recorded order message if the nurse can hear and understand it clearly. E. beat the order back to the provider.

Correct Answer is ["B","C","E"]

Explanation

A. Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B. Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C. Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D. Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E. Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.

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A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).

Correct Answer is ["A","B","C"]

Explanation

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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