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.

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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Correct Answer is B

Explanation

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

A. At the hip region B. Uneven shoulder and pelvic heights C. United tinge of moben of the hips D. Exaggerated curvature of the sacrum

Correct Answer is B

Explanation

Choice A reason:

At the hip region is incorrect because it does not specify any clinical manifestation indicative of scoliosis.

Choice B reason

Uneven shoulder and pelvic heights are the correct position. Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often causing the spine to appear as an "S" or "C" shape when viewed from the back. When performing scoliosis screenings, the school nurse should look for signs that may indicate scoliosis, such as uneven shoulder and pelvic heights.

Choice C reason:

United tinge of moben of the hips is incorrect because it does not describe a known clinical manifestation of scoliosis and appears to contain typographical errors.

Choice D reason:

Exaggerated curvature of the sacrum is incorrect because it is not a characteristic clinical manifestation of scoliosis. The curvature of the sacrum is normal and not related to scoliosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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