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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Hypoglycemia (low blood sugar) is not a common adverse effect of atorvastatin.
Choice B Reason:
Daytime drowsiness is not a typical side effect of statin medications and is more commonly associated with other types of medications, such as sedatives or sleep aids.
Choice C Reason:
Muscle pain is correct. The nurse should instruct the client to monitor and report muscle pain (myalgia) to the healthcare provider when taking atorvastatin. Myalgia is a potential adverse effect of statin medications, and in rare cases, it can progress to a more serious condition called rhabdomyolysis, which involves muscle breakdown and can lead to kidney damage. Therefore, any new or unexplained muscle pain, tenderness, or weakness should be reported promptly to the healthcare provider for evaluation.
Choice D Reason:
Palpitations (rapid or irregular heartbeats) are not commonly associated with atorvastatin use. If a client experiences palpitations, it may be related to other factors or conditions and should be evaluated separately.
Correct Answer is A
Explanation
Choice A Reason:
Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.
Choice B Reason:
Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.
Choice C Reason:
Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.
Choice D Reason:
Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.
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