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 C

Explanation

A. The nurse is not responsible for obtaining informed consent. This is the responsibility of the healthcare provider performing the procedure, who must explain the risks, benefits, and alternatives to the client. The nurse may assist in ensuring the client has the necessary information, but the final responsibility for obtaining consent lies with the provider.

B. Explaining the risks and benefits of the procedure is part of the informed consent process.
The client needs to be informed about potential risks, benefits, and alternatives before giving consent.

C. This is correct. The nurse's role in the informed consent process is to witness the client's signature after the healthcare provider has explained the procedure, risks, and benefits. The nurse verifies that the client is signing voluntarily and understands the consent form, but the nurse does not provide the explanation.

D. Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.

A. Request a prescription for an indwelling urinary catheter. B. Take the client to the bathroom every 2 hr. C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes. E. Use adult diapers to prevent frequent clothing changes.

Correct Answer is B

Explanation

A. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.

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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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Explanation

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