A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Instruct the client to bear down during rectal tube insertion.

Administer a second enema if results are not clear.

Assist the client to a right Sims' position

Insert the rectal tube in the direction of the client's umbilicus.

Answer and Explanation

The Correct Answer is C

When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.

The other options are not correct because:

a) The client should not bear down during rectal tube insertion.

b) Administering a second enema if results are not clear is not mentioned as a safety precaution.

d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.

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Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

A. Decreased platelets B. Decreased hemoglobin C. Increased iron level D. Increased erythrocyte sedimentation rate

Correct Answer is D

Explanation

ESR is a laboratory test that measures the rate at which red blood cells settle in a vertical tube of blood over a specific period of time. An elevated ESR is a nonspecific indicator of inflammation in the body, including infections. In the presence of an infection, the body releases certain substances that can increase the rate at which red blood cells settle, leading to an elevated ESR.

Decreased platelet count is not typically associated with infection. Low platelet count, known as thrombocytopenia, can be caused by various factors such as certain medications, autoimmune disorders, or bone marrow disorders. Infection may cause other changes in blood counts, but decreased platelets are not a direct indicator of infection.

Decreased hemoglobin levels, known as anemia, can be caused by various factors such as nutritional deficiencies, chronic diseases, or blood loss. While some infections can lead to anemia indirectly, decreased hemoglobin is not a specific indicator of infection.

Increased iron levels, known as hyperferritinemia, can occur in various conditions, including infections, but it is not a direct indicator of infection. It is important to assess the overall clinical picture and other laboratory findings to determine the cause of increased iron levels.

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A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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