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 B
Explanation
Rationale:
A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.
B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.
C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.
D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.
Correct Answer is ["B","D","E","F","H","I"]
Explanation
Rationale:
A. Typically involved in helping clients with activities of daily living due to physical or cognitive impairments, which is not the primary focus in this scenario.
B. May be involved if there is a need for possible surgical management due to complications or disease progression. Surgical intervention can be necessary for Crohn's disease, particularly if there are abscesses, strictures, or fistulas.
C. While important in general rehabilitation, physical therapy is not specifically indicated in this case unless there are complications affecting physical mobility.
D. The provider ordered Magnetic Resonance Enterography (MRE) to evaluate the small intestines and pelvis. A radiologist will interpret imaging studies to assess disease severity, fistulas, strictures, or abscesses.
E. Essential for managing nutritional needs, especially given the client's weight loss and inability to keep food down. A dietitian can help develop a plan to address nutritional deficiencies and manage symptoms through diet.
F. A specialist in gastrointestinal diseases who will likely be a key member of the team for managing and evaluating the client's Crohn's disease, overseeing medical and therapeutic interventions.
G. Generally involved if there are issues with swallowing or speech, which is not indicated here.
H. The client is on corticosteroids and may need immunosuppressive therapy, which requires medication management. A pharmacist ensures the correct dosage, drug interactions, and education on potential side effects.
I. Important for addressing psychosocial issues, such as the client's frustration and possible depression. They can assist with coping strategies, support services, and facilitating access to community resources.
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