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 D

Explanation

A. Administering an analgesic by mouth (PO) may not provide immediate relief for the pain at the insertion site. It is more effective to address the issue directly by repositioning the IV catheter.
B. Requesting a prescription for a central venous access device is not necessary in this situation. If peripheral IV access is indicated, the nurse should aim to find a suitable site for insertion.
C. Administering a local anesthetic may not be necessary if the pain is solely related to the insertion of the IV catheter. Repositioning the catheter to a more comfortable site is a more appropriate first step.
D. If the client reports pain at the insertion site after the IV catheter has been placed, it may indicate that the catheter is not properly positioned or may be causing discomfort. In this case, it is appropriate for the nurse to remove the catheter and select a different site for insertion.

A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. Two nurses using a friction-reducing device D. One nurse lifting the client's legs as the client uses a trapeze bar

Correct Answer is C

Explanation

A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

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