A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Place the client in the prone position.

Insert the lubricated tip 2.5 cm (1 in) into the anal canal.

Hang the solution bag 7.5 cm (3 in) above the rectum.

Raise the solution bag if the client exhibits pain during the procedure.

Encourage the client to retain the enema solution for 10 min.

Answer and Explanation

Correct Answer : E

A. Place the client in the prone position. The client should be placed in the Sims' (left lateral) position for enema administration.
B. Insert the lubricated tip 2.5 cm (1 in) into the anal canal. The lubricated tip should be inserted 7.5-10 cm (3-4 inches) into the anal canal.
C. Hang the solution bag 7.5 cm (3 in) above the rectum. The solution bag should be hung approximately 30 cm (12 inches) above the rectum.
D. Raise the solution bag if the client exhibits pain during the procedure. The solution bag should be lowered or the flow rate slowed if the client experiences pain.
E. Encourage the client to retain the enema solution for 10 min. Retaining the enema solution for a period of time enhances its effectiveness.

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Correct Answer is D

Explanation

A. Place throw rugs over thresholds between rooms.Throw rugs can be a tripping hazard, especially for older adults who may have difficulty with balance and mobility.
B. Set the water heater to 54.5° C (130° F). This temperature is too high and can cause burns. It is recommended to set the water heater to no higher than 48.9° C (120° F) to prevent scalding.
C. Set the home thermostat to 26° C (79° F).This temperature might be uncomfortable and is not directly related to safety. It is more important to ensure the home is at a comfortable and safe temperature, typically around 21-23° C (70-73° F).
D. Replace the shower head with a hand-held nozzle. A hand-held shower nozzle can help prevent falls by allowing the client to remain seated while bathing, thereby reducing the risk of slipping.

A. Place an alert sign on the door of the operating room. B. Provide powdered gloves for operating room staff. C. Use multidose vials that have rubber medication stoppers. D. Remove stopcocks from IV tubing.

Correct Answer is A

Explanation

A. Place an alert sign on the door of the operating room. Alerting all staff to the client's latex allergy is crucial to ensure that no latex-containing materials are used during the procedure.
B. Provide powdered gloves for operating room staff. Powdered gloves often contain latex and can increase the risk of latex exposure. Non-latex, powder-free gloves should be used.
C. Use multidose vials that have rubber medication stoppers. Multidose vials with rubber stoppers can contain latex, which poses a risk to the client. Single-dose vials or vials with latex-free stoppers should be used.
D. Remove stopcocks from IV tubing. Stopcocks are not a common source of latex. The focus should be on avoiding latex-containing materials and ensuring all staff are aware of the allergy.

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A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching an older adult client about safety in the home environment. Which of the following actions should the nurse recommend?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client who has a latex allergy and is to undergo surgery. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

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