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 D

Explanation

When a client with active pulmonary tuberculosis (TB) receives appropriate treatment and their sputum cultures consistently show negative results for Mycobacterium tuberculosis, it indicates that the client is no longer contagious. Negative sputum cultures indicate that the infectious bacteria are no longer present or viable in the respiratory secretions, reducing the risk of transmitting the disease to others.

"You will need an annual TB skin test to see if the infection has returned": While it is important for individuals with a history of TB to undergo periodic screening, such as an annual TB skin test or interferon-gamma release assay (IGRA), to detect latent TB infection or potential reactivation, this response is not specifically related to a client with active pulmonary TB.

"You will take medication to treat your illness for the rest of your life": This response is incorrect because active pulmonary TB is typically treated with a combination of antimicrobial medications for a specific duration, usually ranging from 6 to 9 months. It is not a lifelong treatment.

However, individuals with latent TB infection may require longer-term treatment to prevent the development of active TB disease.

"You can expect the medications to turn your urine a blue-green color": This response is incorrect as medications used to treat TB do not typically cause urine discoloration. Medications such as rifampin can cause various side effects, including orange discoloration of bodily fluids like urine, tears, or sweat, but a blue-green color is not associated with TB medications.

A. "You should verify the identity of anyone who wants to remove your baby from the room." B. "You can leave your baby in your room while you walk in the hallway." C. "Your baby should have one identification band on either their right arm or right leg." D. "You can leave the unit with your baby as long as you notify the nurse."

Correct Answer is A

Explanation

The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.

Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.

Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.

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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 reinforcing teaching with a client who has active pulmonary tuberculosis. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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