Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Ask an unlicensed assistive personnel to stay with the client.

Place the bedpan within the reach of the client.

Obtain a bedside commode for the client to use.

Notify the healthcare provider of the client's concerns.

Answer and Explanation

The Correct Answer is C

A. Asking an unlicensed assistive personnel (UAP) to stay with the client does not directly address the client's concern about being unable to make it to the bathroom.
B. Placing the bedpan within the client’s reach may help, but it is less comfortable and dignified than using a commode, which is a better option for an ambulatory client.
C. Obtaining a bedside commode for the client to use is the best intervention as it provides a practical solution that allows the client to relieve herself without the anxiety of having to walk a distance, thus preventing any accidents.
D. Notifying the healthcare provider of the client’s concerns is unnecessary as this situation can be effectively managed by nursing intervention.

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Correct Answer is D

Explanation

A. Asking vague or nonspecific questions can lead to unclear answers, which may hinder the assessment process. Specific and direct questions are more effective.
B. Starting with the most difficult questions may make the client uncomfortable and less willing to share information. It's better to build rapport first.
C. Sharing personal values is not appropriate as it may influence or pressure the client. The focus should be on the client’s values and experiences.
D. Beginning with questions that are less sensitive helps to build rapport and trust with the client, making them more comfortable discussing more sensitive topics later in the conversation.

A. Position the client in a lateral lying position. B. Document the blood pressure and monitor the client. C. Encourage an increase in oral fluid intake. D. Hold the medication and notify the healthcare provider.

Correct Answer is D

Explanation

A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.

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Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Nursing Test Bank

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The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

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