A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)
Confirm the client's identity by checking her wristband
Provide for the client's privacy by dosing the curtains
Asset the cent into the Sims position
Insert the tip of the enema tubing into the client's rectum
The Correct Answer is B,A,C,D
The correct sequence of steps the nurse should take to administer the enema is:
1. Provide for the client's privacy by closing the curtains.
2. Confirm the client's identity by checking her wristband.
3. Assist the client into the Sims position.
4. Insert the tip of the enema tubing into the client's rectum.
Proper infection control measures, preparing the enema solution, monitoring the flow rate, and documenting the procedure are among other important considerations that should be taken into account.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.
The other options mentioned are incorrect:
Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.
Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.
Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.
Correct Answer is C
Explanation
Gastroesophageal reflux disease (GERD) is a condition characterized by the backflow of stomach acid into the esophagus, causing symptoms such as heartburn. Orange juice is highly acidic, and consuming acidic foods and beverages can exacerbate the symptoms of GERD. The acidic nature of orange juice can irritate the esophagus and contribute to increased acid reflux, leading to heartburn.
Sleeping on a large wedge-style pillow can actually help alleviate symptoms of GERD by elevating the head and upper body, reducing the likelihood of acid reflux during sleep.
Eating dinner early in the evening is generally recommended for individuals with GERD as it allows sufficient time for digestion before lying down. This can help prevent acid reflux during sleep.
Consuming low-fat meats is also a favorable choice for individuals with GERD as fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus. However, the options provided do not include any fatty foods, so it is not the primary contributing factor to the client's heartburn in this case.
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