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 ["A","D","E","F"]
Explanation
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.
Correct Answer is C
Explanation
Choice A Reason:
Muscle spasms of the left leg can be uncomfortable and may require interventions such as muscle relaxants or repositioning of the limb, but they do not pose an immediate threat to the client's limb or life.
Choice B Reason:
One fingerbreadth of space between the cast and the skin is an important measurement to ensure that the cast is not too tight, but it does not represent an immediate threat to the client's circulation.
Choice C Reason:
Diminished pulses on the affected extremity. Diminished pulses on the affected extremity, in this case, the left leg with the long leg cast, is the most critical finding that requires immediate attention. It could indicate compromised blood flow, which is a medical emergency. Compromised blood flow can lead to tissue ischemia and necrosis if not promptly addressed.
Choice D Reason:
Ecchymosis (bruising) on the inner left thigh is concerning but may be related to the cast application or other factors. While it should be assessed and monitored, it is not as urgent as diminished pulses.
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