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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
No explanation
Correct Answer is B
Explanation
Choice A Reason:
Removing personal protective equipment (PPE) after leaving the client's room is correct, but it should be done in a way that minimizes the risk of contamination. Proper doffing of PPE is essential to prevent self-contamination.
Choice B Reason:
Wear a gown when assisting the client with personal hygiene. When caring for a client with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term care facility, wearing a gown when assisting the client with personal hygiene is an important infection control measure. MRSA can be transmitted through direct contact with contaminated surfaces or skin, so wearing a gown can help prevent the spread of the bacteria from the client to the healthcare provider's clothing.
Choice C Reason:
Ensuring that negative air pressure is active for the client's room is not typically necessary for MRSA precautions. Negative air pressure rooms are often used for clients with airborne infectious diseases, such as tuberculosis.
Choice D Reason:
Restricting the client's visitors may be necessary in some cases, especially if there is a concern about the potential spread of MRSA to vulnerable individuals. However, visitor restrictions should be implemented based on the facility's policies and guidelines, and they should be communicated clearly to visitors and family members.
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