A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Instruct the client to bear down during rectal tube insertion.

Administer a second enema if results are not clear.

Assist the client to a right Sims' position

Insert the rectal tube in the direction of the client's umbilicus.

Answer and Explanation

The Correct Answer is C

When administering a tap water enema, the client should be assisted to a right Sims position. This position involves lying on the left side with the right knee bent toward the chest.

The other options are not correct because:

a) The client should not bear down during rectal tube insertion.

b) Administering a second enema if results are not clear is not mentioned as a safety precaution.

d) The rectal tube should be inserted in the direction of the sacrum, not the umbilicus.

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Correct Answer is B

No explanation

A. "You should verify the identity of anyone who wants to remove your baby from the room." B. "You can leave your baby in your room while you walk in the hallway." C. "Your baby should have one identification band on either their right arm or right leg." D. "You can leave the unit with your baby as long as you notify the nurse."

Correct Answer is A

Explanation

The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.

Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.

Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.

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A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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