A nurse is preparing to administer 100 mg PO of furosemide (Lasix) to an older adult returning from surgery with fluid volume overload.

The tablets are labeled 40 mg/tablet.

How many tablets should be administered? Do not round.

Choice A rationale

Positioning the client in the left Sim's position is an essential step when administering an enema. This position utilizes gravity to help the enema solution flow downward following the natural curve of the sigmoidcolon and rectum, facilitating better retention of the fluid and optimal distribution for effective bowel evacuation.

Choice B rationale

Enema administration is considered a clean procedure, not a sterile one, because the colon and rectum are not sterile environments. Therefore, the use of non-sterile (clean) gloves is appropriate and sufficient for this procedure to ensure proper hygiene and prevent the transmission of microorganisms, making sterile gloves unnecessary.

Choice C rationale

For an adult client, the tubing or tip of a prepackaged enema should only be inserted about 3 to 4 inches (7.5 to 10 cm) into the anus, following the direction of the umbilicus. Inserting the tubing 6 inches is too far, increases the risk of perforation or injury to the rectal mucosa, and is not the correct technique for safe administration.

Choice D rationale

A Fleets saline enema is a pre-packaged, pre-filled disposable unit that is administered by gently squeezing the bottle, not by gravity from a container bag. Therefore, hanging an enema container 24 inches above the anus is the procedure for a large-volume gravity enema, not the small-volume pre-mixed Fleets enema.

Choice A rationale

General anesthesia and the use of certain medications during surgery, such as opioids, can significantly impair detrusor muscle contraction and/or interfere with the sensation of bladder fullness, leading to temporary urinary retention. Surgical manipulation in the pelvic area can also contribute to temporary nerve dysfunction, which subsequently impairs the normal voiding reflex.

Choice B rationale

Liver failure, while causing numerous systemic effects, primarily affects clotting factors, drug metabolism, and albumin synthesis. It does not directly cause an increased risk of acute urinary retention through a known physiological mechanism; the risk of acute kidney injury from hepatorenal syndrome is an entirely separate and distinct complication.

Choice C rationale

A diet high in calcium oxalate is a risk factor for the formation of calcium oxalate kidney stones (nephrolithiasis). While kidney stones can potentially cause obstruction leading to post-renal acute kidney injury or urinary retention, the diet itself is not the primary direct risk factor for retention compared to immediate post-operative effects.

Choice D rationale

Glomerulonephritis is an inflammatory disease of the kidney glomeruli, often following an infection like streptococcal pharyngitis (not staphylococcal). This primarily leads to hematuria, proteinuria, and decreased glomerular filtration rate, not specifically an increased risk for acute urinary retention, which is a lower urinary tract issue. —.