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. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.

A. Morphine 2.0 mg IV every four hours for severe pain. B. Morphine 2 mg IV every 4 hr PRN for severe pain. C. IV MS 2 mg every 4 hr as needed for severe pain. D. IV MS 2.0 mg every 4 hours PRN for severe pain.

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.

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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 identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is B

Explanation

The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?

Correct Answer is B

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?

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The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.