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 B
Explanation
Choice A Reason:
Illusions typically involve misperceptions of sensory stimuli and can occur in various mental health conditions but are not specific to dementia.
Choice B Reason:
Memory loss that disrupts ADLs is correct. Memory loss that disrupts activities of daily living (ADLs) is a common and characteristic finding in individuals with dementia. Dementia is a progressive neurological disorder that affects cognitive function, including memory. As it progresses, individuals with dementia often experience increasing difficulty with memory and daily functioning.
Choice C Reason:
Pressured speech is a symptom often seen in conditions like mania or bipolar disorder but is not typically associated with dementia.
Choice D Reason:
Catatonia is a neuropsychiatric syndrome that can occur in conditions like schizophrenia but is not a common feature of dementia.
Correct Answer is B
Explanation
Choice A Reason:
Prolonged PT/INR (prothrombin time/international normalized ratio) is not typically seen in pancreatitis. It may be indicative of liver dysfunction or issues with blood clotting.
Choice B Reason:
Elevated lipase levels are commonly seen in clients with pancreatitis. Lipase is an enzyme produced by the pancreas, and when there is inflammation or damage to the pancreas, such as in pancreatitis, it can lead to the release of lipase into the bloodstream. Therefore, an elevated lipase level is a typical laboratory finding in clients with pancreatitis.
Choice C Reason:
Elevated ammonia levels are not typically associated with pancreatitis. Elevated ammonia levels may be seen in clients with liver disease or other metabolic disorders.
Choice D Reason:
Decreased albumin levels are not typically associated with pancreatitis. Decreased albumin levels may be seen in clients with liver disease or malnutrition, but it is not a specific marker for pancreatitis.
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