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 D
Explanation
Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.
Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.
Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.
Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.
Correct Answer is B
Explanation
Choice A Reason:
Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.
Choice B Reason:
Anterior fontanel closed is correct. The anterior fontanel is the soft spot on the top of a baby's head, and it typically closes between 12 to 18 months of age. If the anterior fontanel is closed in a 4-month-old infant, it is considered an early closure, which can be a cause for concern. Early closure of the anterior fontanel can be associated with various underlying medical conditions, such as craniosynostosis (premature fusion of the skull bones) or dehydration.
Choice C Reason:
Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.
Choice D Reason:
Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.