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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping

A. "I will tilt my head forward while inhaling the medication." B. “I will shake the inhaler well right before I use it." C. “I should rinse my mouth out right before I use it." D. "After the first puff, I will wait 10 seconds before taking the second puff."

Correct Answer is D

Explanation

A. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.

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A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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