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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

A. Ask other staff nurses about the level of care the specific staff nurse provides. B. Address the concern with the specific staff nurse. C. Recommend the specific staff nurse be transferred to another unit. D. Notify the human resources department about the request.

Correct Answer is B

Explanation

Rationale:

A. Asking other staff nurses does not address the immediate concern of the client and could lead to gossip or unnecessary complications.

B. Addressing the concern with the specific staff nurse directly is appropriate to understand any issues and to see if there is a valid reason for the client’s request.

C. Recommending transfer without understanding the issue could be premature and might not address the root of the problem.

D. Notifying human resources is a step that may be needed later but should not be the first action; the manager should first address the issue with the staff nurse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Correct Answer is C

Explanation

A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager?

Correct Answer is B

Explanation

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