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
Rationale:
A. Naloxone would reverse morphine effects, which is not relevant to the immediate need for surgical intervention.
B. The client might not be able to sign the consent if under the effects of morphine, and obtaining consent might be delayed.
C. Delaying surgery might not be appropriate if the client’s condition is critical and requires urgent intervention.
D. Implied consent is used in emergencies when a patient cannot provide consent due to their condition, and it is assumed they would consent to life-saving treatment.
Correct Answer is B
Explanation
Rationale:
A. Protective isolation could be managed by any qualified RN, LPN, or AP depending on the complexity.
B. A client actively dying and requiring IV pain medication needs specialized assessment and pain management, which is appropriate for an RN.
C. A client 3 days postoperative requires ongoing care that can be managed by an LPN with supervision.
D. Frequent ambulation is a task that can be managed by an AP, though supervision may be needed.
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