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

Instruct the client to exhale while inserting the rectal tube.

Administer a second enema if the first has poor results.

Insert the tip of the rectal tube 15 cm (6 in).

Administer the enema using cool tap water.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Instructing the client to exhale while inserting the rectal tube is correct. When administering a hypotonic enema to an older adult client, it is important to provide instructions for safe and comfortable insertion of the rectal tube. Instructing the client to exhale while inserting the rectal tube can help relax the anal sphincter, making insertion smoother and less uncomfortable.

Choice B Reason:

Administering a second enema if the first has poor results should be done based on healthcare provider's orders and assessment findings, not automatically as part of the initial instructions.

Choice C Reason:

Inserting the tip of the rectal tube 15 cm (6 in) is not a standard depth for rectal tube insertion when administering an enema. The depth of insertion should be based on the client's anatomy and the type of enema being administered.

Choice D Reason:

Administering the enema using cool tap water is not specific to hypotonic enemas. The temperature of the enema solution should be appropriate for the client, typically lukewarm or at body temperature, to prevent discomfort or injury.

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Correct Answer is D

Explanation

The cervical cap should be left in place for a minimum of 6 hours after intercourse but should not exceed a total of 48 hours of continuous use. Leaving it in place for longer periods may increase the risk of toxic shock syndrome (TSS) and other potential complications. Using a cervical cap in combination with a spermicide is the recommended practice for maximizing its effectiveness. Spermicide helps immobilize or kill sperm, providing an additional barrier against pregnancy when used with the cervical cap.

Using the cervical cap during the menstrual cycle is not a recommended practice for contraception. The cervical cap is primarily used during sexual activity as a barrier method of contraception and is not specifically designed for use during menstruation.

While it is important for the provider to initially fit and size the cervical cap for the client, routine checks every 6 months are not necessary. However, it is still important for the client to regularly inspect the cap for any signs of damage or deterioration and replace it as needed.

A. Request an x-ray of the preschooler's neck. B. Initiate droplet precautions. C. Monitor the preschooler's urine for protein. D. Administer fluconazole to the preschooler.

Correct Answer is B

Explanation

Choice A Reason:

Requesting an x-ray of the preschooler's neck is not typically indicated for RSV. RSV primarily affects the respiratory system, and neck x-rays are not a standard diagnostic tool for this condition.

Choice B Reason:

Initiate droplet precautions are incorrect. This is the most appropriate action for RSV. RSV is primarily transmitted through respiratory droplets. Droplet precautions involve wearing a mask and maintaining a safe distance from the infected child to prevent the spread of the virus to others. It's a standard infection control measure for RSV.

Choice C Reason:

Monitoring the preschooler's urine for protein is not relevant to RSV. RSV primarily affects the respiratory system and does not typically cause kidney problems.

Choice D Reason:

Administering fluconazole is not indicated for RSV. Fluconazole is an antifungal medication, and RSV is a viral respiratory infection. Antifungal medications like fluconazole are not effective against viruses like RSV.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new prescription for a cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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