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.
Insert the tip of the rectal tube 15 cm (6 in).
Administer the enema using cool tap water.
Administer a second enema if the first has poor results.
The Correct Answer is A
The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are
incorrect because they can cause injury or discomfort to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Electroconvulsive therapy (ECT) is a procedure that uses a mild electrical current to cause a brief seizure in the brain, which can help treat severe mentalhealth conditions. One of the possible side effects of ECT is short-term memory loss, which usually resolves within a few weeks. Therefore, if the client states that they might have short-term memory loss after the procedure, they indicate an understanding of the procedure and its risks. The other statements are incorrect or irrelevant. ECT does not require a full-liquid diet, a urinary catheter, or cause seizures after the procedure.
Correct Answer is D
Explanation
Answer: D. Elevated lipase
Rationale: Pancreatitis is an inflammation of the pancreas that causes pancreatic enzymes to leak into the bloodstream and damage surrounding tissues. Lipase is one of these enzymes that is produced by the pancreas to digest fats. An elevated lipase level indicates pancreatic injury and is a diagnostic marker for acute pancreatitis. The other laboratory results are not specific to pancreatitis and could be caused by other conditions.
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