A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?
Don sterile gloves prior to the procedure.
Lubricate 1 inch of the tip of the rectal tube prior to insertion.
Place the client into a left Sims' position.
Raise the enema bag if the client experiences cramping.
The Correct Answer is C
A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.
B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
Correct Answer is D
Explanation
A. Decreased hematocrit may be seen in fluid volume excess, not deficit.
B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.
D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.
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