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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A Reason:

Shrimp salad: Shrimp is a type of shellfish, and shellfish are not allowed in a kosher diet.

Choice B Reason:

Roasted salmon. When caring for a client who follows a kosher diet, it's important to provide food that adheres to kosher dietary laws. Kosher dietary laws prohibit the consumption of certain types of seafood (like shrimp and clams) and pork products (like pulled-pork). Therefore, shrimp salad, clam chowder, and pulled-pork sandwich are not suitable for a kosher diet. Roasted salmon, on the other hand, is an acceptable choice for a kosher diet as long as it has been prepared following kosher guidelines. Fish with fins and scales, such as salmon, are generally considered kosher.

Choice C Reason:

Pulled-pork sandwich: Pork is strictly prohibited in a kosher diet, and any pork-based products, including pulled-pork, are not allowed.

Choice D Reason:

Clam chowder: Clams are considered shellfish, and like other shellfish, they are not permitted in a kosher diet.

A. Encourage the client to bathe frequently. B. Apply powder to the client's skin. C. Add moisturizing oil to the client's bath water. D. Place a humidifier in the client's room.

Correct Answer is D

Explanation

Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.

Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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