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.

Nursing Test Bank

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Correct Answer is D

Explanation

a. Oil-based lubricant

Explanation:

The correct answer is a. Oil-based lubricant.

When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.

Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a diﬀerent procedure and indication

Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.

Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body ﬂuids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.

By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.

A. Raise the head of the client's bed to 30 degrees. B. Cleanse the client's body while wearing sterile gloves. C. Remove the client's dentures and close their mouth D. Apply surgical tape to the client's eyes

Correct Answer is A

Explanation

After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.

The other options are not correct because:

b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.

c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.

d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .

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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

A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

Correct Answer is D

Explanation

A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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