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

Don sterile gloves prior to the procedure.

Lubricate 1 inch of the tip of the rectal tube prior to insertion.

Place the client into a left Sims' position.

Raise the enema bag if the client experiences cramping.

Answer and Explanation

The Correct Answer is C

A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.

B.   Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C.   Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D.   Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.

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Correct Answer is D

Explanation

A. Decreased hematocrit may be seen in fluid volume excess, not deficit.

B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.

D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.

A. Unsteady gait B. Report of short-term memory loss C. Hearing loss D. Report of frequent constipation

Correct Answer is A

Explanation

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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