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 A

Explanation

A. Acknowledging that this is a difficult time for the mother is empathetic and supportive. It provides an opportunity for the mother to express her feelings and concerns without placing blame, which can be helpful in managing emotional distress.
B. While reassuring the mother that she did nothing wrong is important, it does not fully address her emotional needs or allow her to express her feelings. It may be perceived as dismissive if not accompanied by empathy.
C. Reassuring the mother about the outcome of surgery is important, but it does not address the emotional impact of her feelings of guilt or responsibility.
D. Asking why the mother thinks it is her fault may not be as supportive or helpful as providing empathy and reassurance. It could potentially lead to further distress rather than addressing the emotional support she needs.

A. Apply a barrier ointment to intact areas that may be exposed to moisture. B. Determine the size and depth of skin breakdown over the sacral area. C. Complete a functional assessment of the client's self-care abilities. D. Establish a toileting schedule to decrease episodes of incontinence.

Correct Answer is B

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

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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?

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Naxlex Comprehensive Predictor Exams

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is A

Explanation

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

Correct Answer is B

Explanation

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