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
Explanation
A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to
the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.
The other options are not correct.
b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.
c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.
d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.
Correct Answer is A
Explanation
The nurse should administer bronchodilators first for severe wheezing. Bronchodilators work by relaxing the muscles in the airways, which helps to open them up and make it easier to breathe.
Option b is incorrect because beta blockers are not typically used to treat asthma and can actually worsen symptoms in some clients.
Option c is incorrect because inhaled steroids are used to reduce inflammation in the airways over time and are not typically used for immediate relief of severe wheezing.
Option d is incorrect because anti-inflammatory agents are used to reduce inflammation in the airways over time and are not typically used for immediate relief of severe wheezing.
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