A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

cool the solution to 65 degrees F

boil the solution and let it cool down.

warm the solution to body temperature

warm the solution in the microwave.

Answer and Explanation

The Correct Answer is C

Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.

Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.

Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.

Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Stress does not cause bright red stool. Dismissing the symptom as stress could delay identification of potentially serious gastrointestinal bleeding.

B. Minimizing the patient’s concern is inappropriate because bright red stool may indicate active lower gastrointestinal bleeding, such as from hemorrhoids, diverticulosis, or other more serious causes.

C. Investigating the cause of bright red stool promptly is essential. Collecting a stool sample and notifying the charge nurse ensures timely assessment, early detection of bleeding, and appropriate interventions to prevent complications.

D. Recommending a colonoscopy may be necessary in the long-term evaluation of bright red stool, but immediate assessment and diagnostic steps should occur first. Scheduling a colonoscopy without initial evaluation is premature and does not address acute concerns.

A. The elderly patient's total body water percentage increases, weight increases, and diet is altered making it easier to become dehydrated. B. Thirst is already diminished, and their percentage of body water is decreased, making them more susceptible to dehydration. C. Their decreased ability to concentrate on many daily functions makes them forget to drink fluids, particularly when they are ill. D. Their weight increases the likelihood that they will become dehydrated.

Correct Answer is B

No explanation

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A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient expresses concerns over having bright red stool. Which response by the nurse is most appropriate?

Correct Answer is C

Explanation

A nurse educator explains to staff nurses that diarrhea can quickly become lifethreatening in elderly patients because

Correct Answer is B

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