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 A
Explanation
Choice A Reason:
Time of last pain medication is correct. This is important for the oncoming nurse to know to ensure timely pain management for the client.
Choice B Reason:
Preferred bath time is incorrect. While it's important to respect the client's preferences, the timing of their bath is typically not as critical to include in the change-of-shift report, especially when compared to more vital information like medication timing.
Choice C Reason:
Admission vital signs is incorrect. Vital signs taken upon admission are usually documented in the client's chart and are not typically included in change-of-shift reports unless there has been a significant change or concern with the client's vital signs during the shift.
Choice D Reason:
Steps required for dressing change is incorrect. While important for the client's care, the specific steps for a dressing change are typically documented in the client's care plan or orders and may not need to be repeated in every shift report unless there's a specific issue or change in the dressing change procedure.
Correct Answer is C
Explanation
Choice A Reason:
Flossing between a 12-month-old's teeth is not typically necessary, as most children do not have enough teeth for flossing at this age. Flossing becomes more important as a child's dentition develops.
Choice B Reason:
Positioning the toothbrush bristles at a 90-degree angle is not appropriate for a 12-month-old child. Parents should use a gentle, circular brushing motion, as this is more effective and less likely to cause discomfort or injury to the child's gums and teeth.
Choice C Reason:
Cleaning the teeth with a small, soft-bristled toothbrush is correct. When teaching a parent about preventing dental caries in a 12-month-old toddler, it's important to provide appropriate guidance for oral care. Using a small, soft-bristled toothbrush is recommended for young children because it is gentle on their gums and teeth. Here's why the other options are not suitable:
Choice D Reason:
Using a 5-inch strip of toothpaste on the toothbrush is excessive for a 12-month-old. The American Academy of Pediatrics recommends using only a small smear or grain-sized amount of fluoride toothpaste for children under 3 years old to minimize the risk of swallowing too much fluoride.
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