A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?

I do my wheelchair exercises sitting in my chair.

I use a suppository every night to have a bowel movement.

I need to catheterize myself twice a day.

I carry a water bottle with me because I drink a lot of water.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.

Choice B rationale:

The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:

The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.

Choice D rationale:

The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.

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Correct Answer is B

Explanation

Choice A rationale:

A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.

Choice B rationale:

Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.

Choice C rationale:

A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.

Choice D rationale:

Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.

A. Assisting the patient into the Sims’ position B. Confirm the patient’s identity by checking their wristband. C. Provide privacy for the patient by closing the curtains. D. Insert the tip of the enema tubing into the patient’s rectum.

Correct Answer is B,C,A,D

Explanation

B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.

C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.

A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.

D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.

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A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which statement by the adolescent indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a patient who is receiving supplemental oxygen for hypoxia. Which of the following findings should the nurse identify as an indication that the intervention was effective?

Correct Answer is B

Explanation

A nurse is caring for a patient who reports constipation. The doctor has ordered an enema. Identify the sequence of steps the nurse should follow to administer the enema.

Correct Answer is B,C,A,D

Explanation

A nurse is gathering data on a patient who has diarrhea. Which of the following findings is a sign of hypokalemia?

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. Which of the following findings should the nurse identify as an indication of an adverse effect of oxygen therapy?

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A nurse is preparing to remove a patient’s urinary catheter. After performing hand hygiene, what should the nurse do next?

A nurse is helping to implement a bowel training program for a patient. To ensure the effectiveness of the program, when should the nurse take the patient to the bathroom?

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A nurse is gathering information on a patient who has pleural effusion. What symptoms should the nurse anticipate?

A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. What action should the nurse take?

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury.
Which statement by the adolescent indicates a need for further teaching?