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,A,D,B
Explanation
Verify that the provider has certified the client's death: Before any postmortem care is initiated, it's crucial to confirm that the client has indeed passed away. This verification is typically done by a healthcare provider, such as a physician or nurse practitioner, who examines the client, checks for signs of life, and makes an official declaration of death.
Determine the family's preferences about care of the body: After the client's death has been certified, the healthcare team should communicate with the family or next of kin to inquire about their preferences regarding the care of the deceased. Families may have specific cultural, religious, or personal requests regarding postmortem care procedures, and it's essential to respect and accommodate these preferences whenever possible.
Remove all equipment and tubes from the client's body: This step involves the removal of any medical equipment, devices, or tubes that may have been in use during the client's medical care. This can include items such as intravenous (IV) lines, catheters, ventilator tubing, and monitoring equipment. Ensuring that all equipment is removed is not only a matter of dignity but also helps prepare the body for viewing by the family, if desired.
Apply identifying name tags onto the client .To maintain accurate identification and tracking of the deceased client, it's common practice to attach identifying name tags or labels to the body. These tags typically contain essential information, such as the client's name, medical record number, and date of birth. This step helps prevent any confusion or mix-up of identities during postmortem procedures and transport.
Correct Answer is ["1.5"]
Explanation
To calculate the required mL of morphine solution needed to administer 30 mg of morphine orally (PO), you can use the following formula:
Volume (in mL) = Amount (in mg) / Concentration (in mg/mL)
In this case, the amount of morphine is 30 mg, and the concentration of the morphine solution is 20 mg/mL.
Volume (in mL) = 30 mg / 20 mg/mL
Volume (in mL) = 1.5 mL
Therefore, the nurse should administer 1.5 mL of the morphine solution to deliver 30 mg of morphine to the client orally.
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