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

No explanation

A. Check the client's ability to use the call light. B. Document the client's risk in the medical record. C. Request a referral for physical therapy D. Place a gait belt in the client's room.

Correct Answer is A

Explanation

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.

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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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Explanation

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