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.
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Related Questions
Correct Answer is D
Explanation
The nurse should identify that the newborn is making audible swallowing sounds as an indication that they are breastfeeding effectively. This indicates that the newborn is able to latch onto the breast and transfer milk effectively.
a) Falling asleep 5 minutes after starting a feeding may indicate that the newborn is not getting enough milk.
b) Having 3 wet diapers each day is not enough for a 5-day-old newborn. A newborn should have at least 6 wet diapers per day.
c) Having a bowel movement every other day is not an indication of effective breastfeeding. A breastfed newborn should have at least 3 bowel movements per day.
Correct Answer is B
Explanation
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.
a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
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