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.

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Correct Answer is C

Explanation

Rationale:

A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.

B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.

C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.

D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.

A. Determine the social skills of the AP. B. Assess the AP's ability to follow the client's teaching plan. C. Provide a clear description of the task to the AP. D. Evaluate the ability of the AP to work with peers.

Correct Answer is C

Explanation

Rationale:

A. Determining social skills is not directly related to task delegation.

B. Assessing ability to follow the client's teaching plan is beyond the scope of AP duties.

C. Providing a clear description of the task ensures that the AP understands what is expected, which is essential for effective delegation.

D. Evaluating ability to work with peers is important but not the primary focus for task delegation.

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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

A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?

Correct Answer is C

Explanation

A nurse is planning to delegate a task to an assistive personnel (AP). Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is preparing to bathe a client. Which of the following actions should the nurse plan to take?

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?

A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?

A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?