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 B
Explanation
Choice A Reason:
Canned green beans is incorrect. While green beans can contain some potassium, they typically have lower potassium content compared to sweet potatoes.
Choice B Reason:
Sweet potatoes are one of the foods highest in potassium. They are an excellent dietary source of potassium, along with other essential nutrients like vitamins and fiber.
Choice C Reason:
Baked chicken breast: Chicken is a good source of protein, but it is not a significant source of potassium.
Choice D Reason:
D. Wheat bread: Wheat bread is not a significant source of potassium either. It is primarily a source of carbohydrates and fiber.
Correct Answer is A
Explanation
Choice A Reason:
Encourage the client to be assertive. One of the goals in managing a client with dependent personality disorder is to gradually increase their independence and self-confidence. Encouraging the client to be more assertive and make decisions for themselves, with appropriate guidance and support, can be beneficial in their long-term recovery. However, it should be done gradually and with the assistance of therapy and counseling. The other options are not appropriate:
Choice B Reason:
Assuming responsibility for making the client’s, decisions would not help the client develop independence and could perpetuate their dependency.
Choice C Reason:
Maintaining a verbal no-harm contract is not specifically related to managing dependent personality disorder. It might be relevant for clients with suicidal ideation or self-harm tendencies, but it's not a primary intervention for this condition.
Choice D Reason:
Limiting the client's social interactions is not a recommended approach. Encouraging healthy social interactions and relationships can be beneficial for clients with dependent personality disorder, as long as they are appropriate and not reinforcing dependency. Explanation
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