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 B.
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.
Correct Answer is D
Explanation
Answer: D. Abnormal Involuntary Movement Scale
Rationale: The Abnormal Involuntary Movement Scale is a diagnostic tool that assesses the severity of tardive dyskinesia, a disorder that results in involuntary repetitive body movements caused by long-term use of antipsychotic drugs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today