Your patient is supposed to get a tap water enema. What medical diagnosis would NOT qualify him for this procedure?
Pneumonia
Edema or Excess Fluid Volume
Hypertension
Diabetes Melitus
The Correct Answer is B
Choice A Pneumonia is not a contraindication for a tap water enema.
Choice B A tap water enema is not recommended for patients with edema or excess fluid volume due to the risk of further fluid overload.
Choice C Hypertension is not a contraindication for a tap water enema unless the patient has other cardiovascular conditions that could be exacerbated by the procedure.
Choice D Diabetes mellitus is not a contraindication for a tap water enema. However, patients with diabetes may need careful monitoring during the procedure due to potential glucose
fluctuations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.
Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.
Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.
Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.
Correct Answer is D
Explanation
Choice A This range of bowel sounds is considered normal. Hyperactive bowel sounds refer to an increased frequency and intensity of bowel sounds, exceeding the upper limit of the normal range.
Choice B Bowel sounds less than the normal range might indicate decreased bowel motility but are not associated with hyperactive bowel sounds.
Choice C Absent bowel sounds would be concerning and may indicate an ileus or other gastrointestinal issue, but it is not associated with hyperactive bowel sounds.
Choice D Hyperactive bowel sounds are characterized by an increased frequency and intensity of bowel sounds, exceeding the normal range, and are likely to be documented in a patient with abdominal pain.
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