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 C
Explanation
The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.
Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of
the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.
Correct Answer is D
Explanation
The correct answer is D.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.
The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
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