A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Hold the container of solution 30 cm (12 in) above the anus.

Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.

Hold the container of solution level with the client's upper hip.

Keep the container of solution at a level to maintain client comfort.

Answer and Explanation

The Correct Answer is A

A.   This is the appropriate height to allow the fluid flow by gravity.
B.   This is such a short distance and the fluid wouldn't flow as desired.
C.   Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D.   This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

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Correct Answer is D

Explanation

A. Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B. Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C. Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D. Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.

A. Request a prescription for an indwelling urinary catheter. B. Take the client to the bathroom every 2 hr. C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes. E. Use adult diapers to prevent frequent clothing changes.

Correct Answer is B

Explanation

A. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.

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A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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