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

A.Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.

B.In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.

C.Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.

D.Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.

A. Administer diuretics. B. Place on bedrest C. Limit fluid intake. D. Apply support stockings.

Correct Answer is D

Explanation

Answer: D. Apply support stockings.

Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.

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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 has an indwelling catheter with a urinary drainage system.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

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