Which of these enema orders would should the nurse question?
A Kayexalate enema for a patient with severe hypokalemia
A hypertonic solution enema for a patient with fluid overload volume excess
A normal saline enema to be repeated until the patient passes stool is obtained
An oil retention enema for a patient with constipation
The Correct Answer is A
Choice A reason: A Kayexalate enema for severe hypokalemia should be questioned, as Kayexalate removes potassium to treat hyperkalemia, not hypokalemia. Administering it for low potassium would worsen the condition, risking arrhythmias, making this an incorrect and dangerous order.
Choice B reason: A hypertonic solution enema for fluid volume excess is appropriate, as it draws fluid into the bowel, aiding evacuation and reducing systemic fluid overload. This aligns with the patient’s condition, making it a correct order that does not require questioning.
Choice C reason: A normal saline enema repeated until stool is produced is safe, as saline is isotonic and effective for constipation relief without causing fluid or electrolyte imbalances. This is a standard order, making it appropriate and not requiring no questioning.
Choice D reason: An oil retention enema for constipation is appropriate, as it lubricates stool, facilitating evacuation. This is a standard treatment for relieving constipation, aligning with the patient’s needs, making it a correct order that does not require questioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Holding breath for 10 seconds after inhaling albuterol allows medication deposition in the lungs, maximizing bronchodilation. This demonstrates correct technique, ensuring effective asthma relief, making it the correct indicator of understanding.
Choice B reason: Exhaling during medication release expels the drug, reducing lung deposition and effectiveness. Proper technique involves inhaling during actuation, making this incorrect and indicative of poor inhaler use understanding.
Choice C reason: A quick inhalation during medication release is suboptimal, as slow, deep inhalation ensures better drug delivery. This rushed technique reduces efficacy, making it incorrect for demonstrating proper inhaler use.
Choice D reason: Waiting 10 minutes between inhalations is excessive; albuterol doses are typically 1–2 minutes apart. This indicates misunderstanding of dosing intervals, making it incorrect for proper inhaler technique.
Correct Answer is B
Explanation
Choice A reason: Tiny blood clots in the urine (hematuria) suggest urinary tract infection or trauma, not directly related to incontinence or mobility issues. Skin irritation from prolonged urine exposure is more expected, making this finding less likely in this patient patient.
Choice B reason: Skin irritation and redness in the perineal area are expected in urinary incontinence and impaired mobility, as prolonged moisture and pressure cause maceration and dermatitis. This is a common complication requiring skin protection, making it the correct finding finding.
Choice C reason: Increased urinary frequency may occur in incontinence but is not the primary concern compared to skin damage from constant moisture due to impaired mobility. Perineal irritation is a more direct consequence, making this less specific to the described scenario.
Choice D reason: Decreased urine specific gravity indicates dilute urine, unrelated to incontinence or mobility. It may occur in overhydration, but skin irritation from urine exposure is the most relevant finding in this patient context, making this incorrect incorrect.
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