A nurse is caring for an elderly client experiencing gastrointestinal discomfort.
Retain the fluid for a few minutes before expelling
Be aware of potential electrolyte imbalances
Avoid using enemas frequently
Understand the benefits of different solutions
Follow provider instructions on enema type and solution
Increase intake of fluids to aid bowel movement
Correct Answer : A,C,E
Rationale:
- Retaining the fluid allows the enema to soften stool and stimulate peristalsis effectively.
- Avoiding frequent use prevents dependence and irritation of the bowel.
- Following provider instructions ensures safe and appropriate selection of enema type and solution for the client’s condition.
- Electrolyte imbalances, benefits of solutions, and fluid intake are important considerations but are broader teaching points, not immediate enema administration instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Probiotics, such as yogurt with live cultures, can promote healthy gut flora and improve bowel regularity.
B. Physical activity stimulates peristalsis, helping prevent constipation, especially in clients who have reduced mobility postoperatively.
C. Low-fiber foods worsen constipation. Clients should consume high-fiber foods such as fruits, vegetables, and whole grains to promote bowel movements.
D. Adequate hydration softens stool and prevents fecal impaction, particularly important for clients taking opioid pain medications.
E. Drinking warm or hot liquids can actually help stimulate bowel movements. There is no need to avoid them.
Correct Answer is B
Explanation
Rationale:
A. Delaying discussion until after signing the consent form does not address the client’s immediate anxiety or provide needed education.
B. Providing information about sedation reassures the client that discomfort during the colonoscopy will be minimized and helps reduce anxiety. It is accurate, therapeutic, and informative.
C. Acknowledging the recommendation without addressing the anxiety does not provide reassurance or information about pain management.
D. While humorous, this comment does not address the client’s concern about pain and is not considered a therapeutic response.
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