A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Instruct the client to exhale while inserting the rectal tube.

Administer a second enema if the first has poor results.

Insert the tip of the rectal tube 15 cm (6 in).

Administer the enema using cool tap water.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Instructing the client to exhale while inserting the rectal tube is correct. When administering a hypotonic enema to an older adult client, it is important to provide instructions for safe and comfortable insertion of the rectal tube. Instructing the client to exhale while inserting the rectal tube can help relax the anal sphincter, making insertion smoother and less uncomfortable.

Choice B Reason:

Administering a second enema if the first has poor results should be done based on healthcare provider's orders and assessment findings, not automatically as part of the initial instructions.

Choice C Reason:

Inserting the tip of the rectal tube 15 cm (6 in) is not a standard depth for rectal tube insertion when administering an enema. The depth of insertion should be based on the client's anatomy and the type of enema being administered.

Choice D Reason:

Administering the enema using cool tap water is not specific to hypotonic enemas. The temperature of the enema solution should be appropriate for the client, typically lukewarm or at body temperature, to prevent discomfort or injury.

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Correct Answer is C

Explanation

Choice A Reason:

Supine is incorrect. The supine position (lying flat on the back) is not the best choice because it can increase the risk of airway obstruction and discomfort, especially if there is swelling or drainage from the surgical site.

Choice B Reason:

Left lateral is incorrect. The left lateral position (lying on the left side) is not typically used after a thyroidectomy because it does not provide the same advantages for airway management, swelling reduction, and comfort as the semi-Fowler's position.

Choice C Raeson:

Semi-Fowler's position is the most appropriate choice for a client who is postoperative following a subtotal thyroidectomy for several reasons:

Airway Management: Elevating the head of the bed in a semi-Fowler's position helps maintain airway patency and reduces the risk of airway obstruction or compression of the surgical site, which is important for respiratory comfort and function.

Swelling and Drainage: After thyroid surgery, there may be swelling and drainage from the surgical site. The semi-Fowler's position can assist in reducing swelling and facilitating proper drainage.

Comfort: This position generally provides greater comfort for the client, especially when there may be discomfort or soreness at the surgical site.

Choice D Reason:

Dorsal recumbent is incorrect. The dorsal recumbent position (lying on the back with knees flexed and feet flat on the bed) is also not the most appropriate choice for post-thyroidectomy care because it does not offer the same benefits as the semi-Fowler's position in terms of airway management, swelling reduction, and comfort.

A. Apply talcum powder daily after bathing in order to prevent diaper rash. B. Use an alkaline soap to bathe the baby. C. Perform sponge baths until the baby's umbilical cord falls oﬀ. D. Ensure the bath water is at least 96 degrees Fahrenheit.

Correct Answer is C

Explanation

Explanation:

Sponge baths are recommended until the umbilical cord stump falls oﬀ, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath.

Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin.

The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.

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A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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