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 C

Explanation

A. 1+ pitting edema is mild, with a slight indentation.

B. 4+ pitting edema is severe, with a deep indentation that lasts a long time.

C. 3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.

A. Date of birth B. Diagnosis C. Identification number D. Name E. Room Number

Correct Answer is ["A","C","D"]

Explanation

A. Date of birth is a commonly used identifier to confirm the client's identity.

B. Diagnosis is not an appropriate identifiers for confirming a client's identity.

C. Identification number is a unique identifier assigned to each client, helping ensure accurate identification.
D. Name is a fundamental identifier and should be used in combination with other identifiers to verify the client's identity.
E. Room number is not an appropriate identifiers for confirming a client's identity.

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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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