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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?

A.

Instruct the client to exhale while inserting the rectal tube.

B.

Insert the tip of the rectal tube 15 cm (6 in).

C.

Administer the enema using cool tap water.

D.

Administer a second enema if the first has poor results.

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.

Correct Answer is C

Explanation

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.

The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.

The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

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