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 B

Explanation

A. Dizziness during perineal cleansing is not a common concern and should not be included as a standard part of perineal care instructions.
B. For male clients, the foreskin should be retracted gently if it is retractable to clean the area underneath. However, if the foreskin is not retractable or if retraction causes discomfort, it should not be forced. This instruction is crucial for proper hygiene and prevention of infection.
C. While an erection can occur, it is not a standard concern to highlight during perineal care education. The focus should be on proper technique and hygiene.
D. Shaving the pubic area is not necessary for perineal care and can potentially cause irritation or increase the risk of infection. Proper hygiene practices are more important than hair removal.

A. Avoids adjusting the height of the hand grips. B. Holds the crutch 6 inches (15 cm) to the side. C. Fits the crutch 2 finger widths from axilla. D. Walks with the arms fully extended.

Correct Answer is C

Explanation

A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.

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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

Naxlex Comprehensive Predictor Exams

The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?

Correct Answer is B

Explanation

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

Correct Answer is C

Explanation

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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?