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.
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Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Applying talcum powder daily after bathing is not recommended, as it can pose a risk to the baby's respiratory health if inhaled.
Choice B Reason:
The water for a baby's bath should be comfortably warm, but it should not be as hot as 96 degrees Fahrenheit, as this can scald the baby's delicate skin.
Choice C Reason:
"Perform sponge baths until the baby's umbilical cord falls off." This is because newborns typically receive sponge baths until their umbilical cord stump naturally falls off, which usually occurs within the first few weeks of life. It's important to keep the area around the umbilical cord clean and dry to prevent infection. The other options are not recommended:
Choice D Reason:
Using an alkaline soap is not recommended for newborns, as their skin is sensitive. Mild, fragrance-free, and pH-balanced baby soap is typically recommended for a baby's bath.
Correct Answer is B
Explanation
The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.
Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).
Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.
Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts
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