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 D

Explanation

The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.

Option a is incorrect because drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.

Option b is incorrect because seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.

Option c is incorrect because treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.

A. Call EMS if a seizure lasts 5 min or more. B. Restrain the child at the onset of the seizure. C. Oﬀer the child a bubble bath every evening. D. Place the child in a prone position during the seizure.

Correct Answer is A

Explanation

The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.

Explanation:

When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.

Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.

Option c, oﬀering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.

Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other ﬂuids and prevent choking.

Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.

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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

A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client does which of the following?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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