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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
No explanation
Correct Answer is D
Explanation
Answer: D
Rationale:
A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.
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