A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Check the client's medical record for the provider's prescription.

Inform the charge nurse that the client refused the enema.

Explain to the client that the provider prescribed the procedure.

Assure the client that enemas are commonly prescribed for constipation.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.

B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.

C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.

D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. The benchmark for glucose control is 90%, but the percentages reported are consistently below this threshold: 75.29% in Quarter 1, 85.5% in Quarter 2, and 82% in Quarter 3. Improvement is needed to meet or exceed the benchmark.

B. The benchmark is 80.2%, and the percentages are above this threshold: 75.79% in Quarter 1, 80.5% in Quarter 2, and 92% in Quarter 3. No improvement needed as the measure is above the benchmark.

C. The benchmark is 85%, and the percentages reported are: 69% in Quarter 1, 85% in Quarter 2, and 86.2% in Quarter 3. Although Quarter 1 is below the benchmark, Quarter 2 and Quarter 3 meet or exceed the benchmark. Overall, the trend shows improvement.

D. The benchmark is 100%, and the percentages reported are: 90.4% in Quarter 1, 88.2% in Quarter 2, and 92.6% in Quarter 3. Although the percentages are below the benchmark, there is a trend of improvement. However, the measure still requires further enhancement to meet the benchmark.

E. The benchmark for smoking cessation education 4 weeks prior to surgery is 75%. The percentages are below this benchmark in Quarter 1 (70.6%) and Quarter 3 (74%), although it meets the benchmark in Quarter 2 (100%). Consistent adherence to the benchmark needs to be improved.

A. Review the incident of disruptive behavior and discuss the principles of civility and respect. B. Review mandatory nursing skills and competencies for nursing. C. Meet to talk about mislabeling of laboratory specimen and discuss the policy and procedure for how to do it correctly. D. Review near miss fall and fall precautions, bed position, rounding, and appropriate use of bed or chair alarms. E. Review central line infections rates and causes. Include review of proper care of central lines.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Review the incident of disruptive behavior and discuss the principles of civility and respect.

Unit meeting

Rationale: The incident of disruptive behavior between nurses should be addressed in a unit meeting to foster a culture of respect and teamwork. Discussing this issue with the entire team will help reinforce appropriate behavior and conflict resolution.

Review mandatory nursing skills and competencies for nursing.

Unit meeting

Rationale: Mandatory nursing skills competencies are essential for ensuring that all staff meet the required standards. This should be reviewed during the unit meeting to ensure that all nurses are up to date and compliant with required competencies.

Meet to talk about mislabeling of laboratory specimens and discuss the policy and procedure for how to do it correctly.

Individual Team Member

Rationale: The issue of mislabeling specimens should be addressed directly with the specific individual (TJ, the AP) involved. It’s important to provide corrective feedback and retraining for the individual responsible for the issue.

Review near miss fall and fall precautions, bed position, rounding, and appropriate use of bed or chair alarms.

Unit meeting

Rationale: The near-miss fall incident involves issues that are relevant to the entire unit, such as bed position, use of bed alarms, and rounding practices. Discussing this in a unit meeting can help prevent future incidents by educating all staff on proper procedures.

Review central line infections rates and causes. Include review of proper care of central lines.

Unit meeting

Rationale: Reviewing central line infection rates and proper care is important for the entire team to ensure adherence to best practices and reduce infection rates. This is best addressed in a unit meeting to promote awareness and compliance among all staff.

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A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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