A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
Check the client's medical record for the provider's prescription.
Inform the charge nurse that the client refused the enema.
Explain to the client that the provider prescribed the procedure.
Assure the client that enemas are commonly prescribed for constipation.
The Correct Answer is A
Rationale:
A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.
B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.
C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.
D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reassign the task to another nurse: While reassignment may be an option, it does not address the underlying issue. Ensuring the LPN has the knowledge and skill to complete the task is more effective in addressing both immediate and future concerns.
B. Report the issue to the unit manager: Reporting to the manager might be appropriate if the issue persists or reflects repeated non-compliance. However, verifying the LPN's competence and addressing the problem directly should be the first step.
C. Change the client’s dressing: While changing the dressing resolves the immediate client need, it does not address the issue of delegation or why the task was not completed. This approach bypasses the opportunity to assess and support the LPN.
D. Verify the LPN knows how to do a dressing change: Before taking further action, the charge nurse should determine why the task was not completed. If the LPN lacks the knowledge or skill to perform a dressing change, the nurse must address this gap and provide appropriate education or support to ensure client care is not compromised.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A,C"}}
Explanation
Time Management: Concerns related to how the nurse manages their time, including the efficiency of their work and how they handle their responsibilities (e.g., frequent trips to the supply room, notes written on small pieces of paper, coming early and staying late to chart).
Delegation: Issues related to the nurse's ability to delegate tasks effectively (e.g., covering other nurses' clients for breaks, which could suggest issues with delegation).
Professional Behavior: Concerns related to the nurse's conduct and adherence to professional standards (e.g., frequent personal phone calls during shifts, not taking breaks, missed prescriptions, covering other nurses' clients without taking breaks).
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