Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Ask an unlicensed assistive personnel to stay with the client.

Place the bedpan within the reach of the client.

Obtain a bedside commode for the client to use.

Notify the healthcare provider of the client's concerns.

Answer and Explanation

The Correct Answer is C

A. Asking an unlicensed assistive personnel (UAP) to stay with the client does not directly address the client's concern about being unable to make it to the bathroom.
B. Placing the bedpan within the client’s reach may help, but it is less comfortable and dignified than using a commode, which is a better option for an ambulatory client.
C. Obtaining a bedside commode for the client to use is the best intervention as it provides a practical solution that allows the client to relieve herself without the anxiety of having to walk a distance, thus preventing any accidents.
D. Notifying the healthcare provider of the client’s concerns is unnecessary as this situation can be effectively managed by nursing intervention.

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Correct Answer is D

Explanation

A. The medication should not be kept or stored once it has been removed from its original packaging, especially if it’s not administered. Proper disposal or return to the pharmacy is required.
B. The medication should not be put back in the client’s medication box due to safety and contamination concerns.
C. While controlled substances need careful management, the client’s refusal must be respected, and the medication must be disposed of properly if not administered.
D. Having another nurse witness the disposal of the medication ensures that it is done according to protocols and provides accountability. This practice helps maintain the integrity and safety of medication handling.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Challenge members of the healthcare team whose opinions differ from the wishes of the client. C. Educate the client about current nursing literature findings related to the client's ethical dilemma. D. Listen to the ethics committee discussions and then inform the client what actions should be taken.

Correct Answer is A

Explanation

A. It is essential for the nurse to develop self-awareness of their personal values to avoid imposing these values on the client. As an advocate, the nurse's primary role is to represent the client's wishes and ensure they are respected, regardless of the nurse's personal beliefs or values.
B. While challenging differing opinions may sometimes be necessary, it is more important to ensure the client's wishes are clearly communicated rather than simply opposing differing views.
C. Educating the client on relevant nursing literature is not the primary role of advocacy in this context. The focus should be on the client’s values and wishes rather than on influencing them with professional literature.
D. Listening to discussions is important, but the nurse's role as an advocate is to ensure the client's voice is heard during the discussions, rather than informing the client of decisions after the fact.

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Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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