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

Explanation

A. Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B. Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C. Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D. Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.

A. Assist a client to ambulate using a gait belt. B. Review a low-sodium diet for a client who has hypertension. C. Feed a client who had a stroke 3 months ago. D. Bathe a client who had an amputation 2 days ago. E. Expllain oral hygiene to a client receiving chemotherapy.

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

Explanation

Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.

Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.

Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.

Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.

Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.

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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

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

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

Explanation

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