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. The risk manager.
Rationale: The risk manager is responsible for identifying and managing potential or actual sources of harm or loss in a healthcare organization. The risk manager would be interested in analyzing the data on zolpidem use and fall rate, implementing preventive measures, and reporting adverse events to regulatory agencies if needed. The surgeon may not be directly involved in prescribing zolpidem or monitoring its effects on postoperative clients. The case manager may not have access to or authority over medication administration policies or practices. The pharmacist may be able to provide information on zolpidem's pharmacokinetics and pharmacodynamics, but may not be able to address the organizational factors that contribute to fall risk.
Correct Answer is C
Explanation
Going to bed at the same time every night helps to establish a regular sleep pattern and promote sleep quality.
Eating late, exercising before bed, and having noise in the bedroom can interfere with falling asleep or staying asleep.
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