Before administering a cleansing enema to an 80-year-old patient, the patient says, “I don’t think I will be able to hold the enema.” Which is the next priority nursing action?
Assisting the patient to the bedside commode and administering the enema
Inserting a rectal plug to contain the enema solution after administering
Rolling the patient into right-lying Sims’ position
Positioning the patient in the dorsal recumbent position on a bedpan
The Correct Answer is D
Choice A reason: Assisting to the bedside commode is impractical if the patient cannot hold the enema, as it risks spillage and discomfort. Enemas stimulate bowel evacuation by distending the colon, triggering peristalsis. Administering in a commode for an elderly patient with retention concerns increases fall risk and is not the priority action.
Choice B reason: Inserting a rectal plug is not standard practice and risks discomfort or injury in an elderly patient. Enemas work by stimulating peristalsis via fluid volume, requiring retention for efficacy. A plug is not a recognized medical device for this purpose, making positioning on a bedpan the safer, more practical priority.
Choice C reason: Right-lying Sims’ position aids enema administration but does not address the patient’s inability to retain fluid. The position facilitates fluid flow but is secondary to ensuring containment. Elderly patients have weaker sphincter control, making dorsal recumbent on a bedpan the priority to manage potential leakage and maintain dignity.
Choice D reason: Positioning in dorsal recumbent on a bedpan is the priority, as it allows enema administration while containing potential leakage in an elderly patient with retention concerns. This position supports sphincter relaxation and fluid delivery while minimizing mess, ensuring comfort and dignity. It addresses the patient’s concern effectively, aligning with safe practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sodium 138 mEq/L (normal 135-145 mEq/L) is within normal range. Sodium regulates osmotic balance and nerve conduction. Normal levels do not explain tremors, which are often linked to neurological or electrolyte imbalances, like low magnesium. In the context of acute tremors, sodium is not a concern compared to magnesium deficiency.
Choice B reason: Chloride 100 mEq/L (normal 98-106 mEq/L) is normal and does not contribute to tremors. Chloride supports acid-base balance and neuronal inhibition via GABA receptors. Tremors are more likely caused by low magnesium, which affects neuromuscular excitability. Normal chloride levels do not warrant concern in this acute neurological presentation.
Choice C reason: Potassium 4.1 mEq/L (normal 3.5-5.0 mEq/L) is normal and unlikely to cause tremors. Potassium regulates membrane potential and muscle contraction. Tremors are more associated with magnesium deficiency, which increases neuronal excitability. Normal potassium does not explain the neurological symptoms, making it a lower priority than magnesium in this scenario.
Choice D reason: Magnesium 1.0 mEq/L (normal 1.7-2.2 mEq/L) indicates hypomagnesemia, which causes tremors by increasing neuromuscular excitability. Magnesium stabilizes neuronal membranes and regulates calcium channels. Low levels disrupt nerve signaling, leading to tremors and potential seizures. This critical imbalance requires urgent correction, making it the most concerning lab value in this scenario.
Correct Answer is D
Explanation
Choice A reason: Hemoglobin of 11.3 g/dL is low but not specific to malnutrition, as it may indicate anemia from various causes, like iron deficiency or chronic disease. Malnutrition affects protein levels more directly. This value requires further investigation but does not confirm malnutrition, as it reflects red blood cell status, per hematological assessment.
Choice B reason: Creatinine of 1.9 mg/dL suggests renal impairment, as it exceeds normal ranges (0.6-1.2 mg/dL), reflecting reduced kidney filtration. Malnutrition typically lowers creatinine due to muscle wasting, not elevates it. This value indicates kidney dysfunction, not nutritional status, making it irrelevant to malnutrition assessment, per renal physiology.
Choice C reason: Hematocrit of 56% indicates hemoconcentration, often from dehydration, not malnutrition. Malnutrition may cause anemia, lowering hematocrit. Elevated hematocrit reflects increased red blood cell proportion, unrelated to protein-energy deficits. This finding does not align with malnutrition’s impact on nutritional biomarkers, per laboratory diagnostic standards.
Choice D reason: Serum albumin of 2.8 g/dL (normal 3.5-5.0 g/dL) indicates malnutrition, as low levels reflect reduced protein synthesis due to inadequate dietary intake. Albumin is a sensitive marker of chronic nutritional status, decreasing in protein-energy malnutrition. This finding directly correlates with malnutrition’s physiological impact, per nutritional assessment guidelines.
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