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 A

Explanation

A. Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.

C. Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

A. "While your child is in this phase, feed him anything that he will eat." B. "Your child's change in eating habits must concern you." C. "As long as your child appears healthy, no intervention is necessary." D. "Increase the amount of calories and water your child consumes."

Correct Answer is C

Explanation

A. Encouraging feeding anything the child will eat might lead to poor nutrition. It's important to ensure a balanced diet.
B. Acknowledging the concern is valid, but the nurse should provide guidance rather than just expressing concern.
C. This response acknowledges the concern but reassures the parent that, if the child appears healthy, no immediate intervention is necessary, promoting a balanced approach.
D. Increasing calories and water without a specific reason or assessment may not address the underlying issue and is not the initial recommended intervention.

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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?

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