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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The use of "2.0 mg" is incorrect because trailing zeros can lead to dosage errors. The correct documentation should avoid trailing zeros to prevent misinterpretation.
B. "Morphine 2 mg IV every 4 hr PRN for severe pain" is the correct format. It uses the full name of the drug, avoids abbreviations that could be confused, and follows best practices for documenting as-needed (PRN) medications.
C. Using "MS" instead of "morphine" is not recommended because "MS" can be confused with magnesium sulfate or other medications. The full drug name should always be used.
D. Similar to option A, the use of "2.0 mg" includes a trailing zero, which should be avoided to reduce the risk of errors in medication administration.
Correct Answer is B
Explanation
A. Hypothyroidism is not directly related to obstructive sleep apnea. While sleep apnea can have various systemic effects, hypothyroidism is not a common complication associated with it.
B. Obstructive sleep apnea is strongly associated with an increased risk of hypertension. The repeated episodes of oxygen desaturation and arousal during sleep can contribute to increased blood pressure and cardiovascular strain.
C. Peptic ulcer disease is not a known complication of obstructive sleep apnea. It is generally associated with factors like H. pylori infection, NSAID use, and stress rather than sleep apnea.
D. Fibromyalgia is a chronic pain syndrome and is not typically associated with obstructive sleep apnea. Sleep apnea can exacerbate fatigue and sleep disturbances but does not directly cause fibromyalgia.
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