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
Choice A Reason:
Attaching a pacifier to the newborn's clothing with a string can be dangerous, as it poses a risk of strangulation. Pacifiers should be used, but they should be the type with a handle designed for infant use.
Choice B Reason:
Placing the newborn face up on a pillow when sleeping is not recommended. The baby should be placed on their back on a firm and flat sleep surface, such as a crib mattress, without pillows, blankets, or other soft bedding items. This helps reduce the risk of sudden infant death syndrome (SIDS).
Choice C Reason:
Placing the newborn's crib near a heat vent during cold weather can lead to overheating, which is a risk factor for SIDS. It's important to maintain a comfortable room temperature for the baby and use appropriate sleep clothing to keep them warm without the need for additional heating devices near the crib.
Choice D Reason:
"I will make sure that I can fit one finger between the mattress and the side of my newborn's crib." This statement indicates an understanding of safe sleep practices for newborns. Ensuring that there is a small gap (about one finger's width) between the mattress and the side of the crib helps prevent the risk of suffocation or entrapment. It allows for proper airflow and reduces the risk of the baby getting stuck between the mattress and the crib.
Correct Answer is D
Explanation
Choice A Reason:
Applying warm, moist packs to the surgical site may not be indicated as it can potentially increase swelling and disrupt the surgical site.
Choice B Reason:
Massaging the lower leg in smooth, long strokes is generally not recommended in the early postoperative period, as it can disturb the surgical site and potentially lead to complications.
Choice C Reason:
When planning care for a client who is postoperative following a knee arthroplasty, placing a pillow under the surgical knee can be beneficial. This helps maintain proper alignment, reduces pressure on the surgical site, and promotes comfort and circulation. Elevating the leg slightly with a pillow can also help reduce swelling and minimize the risk of complications such as deep vein thrombosis (DVT).
Choice D Reason:
Using the continuous passive-motion (CPM) machine intermittently should be done as ordered by the healthcare provider and under their guidance.CPM is typically initiatedearly postoperatively, often within the first 24 hours after surgery.
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