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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Free Nursing Study Resources

Correct Answer is ["1.5"]

Explanation

To calculate the required mL of morphine solution needed to administer 30 mg of morphine orally (PO), you can use the following formula:

Volume (in mL) = Amount (in mg) / Concentration (in mg/mL)

In this case, the amount of morphine is 30 mg, and the concentration of the morphine solution is 20 mg/mL.

Volume (in mL) = 30 mg / 20 mg/mL

Volume (in mL) = 1.5 mL

Therefore, the nurse should administer 1.5 mL of the morphine solution to deliver 30 mg of morphine to the client orally.

A. "Apply talcum powder daily after bathing in order to prevent diaper rash." B. "Ensure the bath water is at least 96 degrees Fahrenheit." C. "Perform sponge baths until the baby's umbilical cord falls off." D. "Use an alkaline soap to bathe the baby."

Correct Answer is C

Explanation

Choice A Reason:

Applying talcum powder daily after bathing is not recommended, as it can pose a risk to the baby's respiratory health if inhaled.

Choice B Reason:

The water for a baby's bath should be comfortably warm, but it should not be as hot as 96 degrees Fahrenheit, as this can scald the baby's delicate skin.

Choice C Reason:

"Perform sponge baths until the baby's umbilical cord falls off." This is because newborns typically receive sponge baths until their umbilical cord stump naturally falls off, which usually occurs within the first few weeks of life. It's important to keep the area around the umbilical cord clean and dry to prevent infection. The other options are not recommended:

Choice D Reason:

Using an alkaline soap is not recommended for newborns, as their skin is sensitive. Mild, fragrance-free, and pH-balanced baby soap is typically recommended for a baby's bath.

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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 preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

A nurse is reinforcing teaching with a new parent about bathing her newborn. Which of the following statements should the nurse include?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5" C (90.5). Which of the following data is the priority for the nurse to monitor?