A nurse is collecting data on a client who reports only being able to tolerate drinking small amounts and having diarrhea for several days. Which of the following findings should the nurse expect?

Rigid abdomen

Decreased bowel sounds

Hypothermia

Dehydration

Answer and Explanation

The Correct Answer is D

A. Rigid abdomen: A rigid abdomen suggests peritonitis or another surgical emergency, not dehydration.

B. Decreased bowel sounds: Diarrhea usually causes hyperactive bowel sounds, not decreased.

C. Hypothermia: Clients with diarrhea or fluid loss usually present with normal or elevated temperatures, especially if infection is involved.

D. Dehydration: Diarrhea and limited fluid intake lead to dehydration, which presents with dry mucous membranes, increased thirst, tachycardia, and concentrated urine.

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Correct Answer is B

Explanation

A. Cleanse the labia: This must be done after donning sterile gloves to maintain asepsis.

B. Don sterile gloves: Sterile technique is required after opening the kit. Gloves must be put on before touching sterile items like swabs or catheters.

C. Cleanse the meatus: This occurs after sterile gloves are worn and before catheter insertion.

D. Lubricate the catheter: Catheter lubrication happens after gloves are on and after cleaning the area.

A. Assist the client to the left Sims' position. B. Put on sterile gloves. C. Hang the enema container 61 cm (24 in) above the anus D. Insert the tubing about 15 cm (6 in) into the anus.

Correct Answer is A

Explanation

A. Assist the client to the left Sims' position: This position uses gravity to promote flow into the rectum and colon and allows the enema to follow the natural direction of the colon.

B. Put on sterile gloves: Clean gloves are sufficient for enema administration. This is a clean, not sterile, procedure.

C. Hang the enema container 61 cm (24 in) above the anus: The correct height is no more than 45 cm (18 inches) to prevent rapid flow and discomfort.

D. Insert the tubing about 15 cm (6 in) into the anus: Insertion should be 7.5 to 10 cm (3 to 4 inches) in adults. Inserting 6 inches increases the risk of injury.

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A nurse is collecting data on a client who reports only being able to tolerate drinking small amounts and having diarrhea for several days. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and placing the pad under the patient, which of the following steps should the nurse perform next?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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