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.
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Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Determining the client's pattern for voiding. The reason why determining the client's pattern for voiding is the first step in implementing a bladder training program for a client who had a stroke is as follows:
Assessment: Before implementing any intervention, it's essential to assess the client's current bladder habits and patterns. Understanding when and how often the client typically voids, as well as any specific triggers or challenges they may have, is crucial information. This assessment helps the nurse create an individualized bladder training plan based on the client's unique needs.
Choice B Reason:
Assisting the client with relaxation techniques may be a helpful intervention in bladder training, but it should come after the assessment of the client's voiding pattern. Relaxation techniques can help the client manage urgency or anxiety related to bladder function, but they should be tailored to the client's specific needs.
Choice C Reason:
Discouraging intake of carbonated beverages is a dietary recommendation that can be a part of a bladder training plan, but it should be based on the client's assessment and preferences. It's important to assess the client's current fluid intake habits and any specific dietary triggers before making recommendations.
Choice D Reason:
Offering toileting opportunities every 1 to 2 hours is a potential intervention in a bladder training program, but it should also be based on the client's voiding pattern assessment. Implementing a toileting schedule without understanding the client's current habits may not be effective or necessary.
Correct Answer is C
No explanation
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