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:
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.
Correct Answer is B
Explanation
Choice A Reason:
Decreased BUN (blood urea nitrogen) level is incorrect. While furosemide can lead to decreased BUN levels, it is not the primary indicator of its effectiveness. BUN levels can be influenced by various factors, including hydration status and kidney function.
Choice B Reason:
Increased urinary output is correct. Furosemide is a diuretic medication often prescribed to clients with heart failure to help manage fluid retention. One of the primary therapeutic effects of furosemide is increased urinary output, which indicates that the medication is effectively removing excess fluid from the body.
Choice C Reason:
Decreased hemoglobin level is incorrect. Furosemide is not directly associated with changes in hemoglobin levels. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are typically not affected by diuretic therapy.
Choice D Reason:
Increased weight of 0.91 kg (2 lb.) is incorrect. An increase in weight is not indicative of the medication's effectiveness. In fact, weight gain could be a sign of fluid retention and heart failure exacerbation, which would suggest that the medication may not be working optimally.
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