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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Extra incandescent lighting improves visibility, reducing fall risk, especially for patients with impaired vision or mobility. Adequate lighting illuminates hazards, enhancing environmental safety, making this the best advice for a safer home.

Choice B reason: Throw rugs increase tripping hazards, particularly for mobility-impaired patients. They can slide or bunch, leading to falls, a leading injury cause, making this an unsafe recommendation for improving home safety.

Choice C reason: Painting the floor black and white may create visual confusion, especially for patients with cognitive or visual impairments, increasing fall risk. Contrasting colors may disorient, making this ineffective and hazardous.

Choice D reason: Handrails painted the same color as walls blend into the background, reducing visibility. Contrasting colors ensure handrails are noticeable, aiding safe mobility, making this an incorrect recommendation for safety.

A. Maintain complete bed rest B. Place light wrapping on the legs and waist C. Encourage early ambulation D. Put pillows under the knees

Correct Answer is C

Explanation

Choice A reason: Complete bed rest increases stasis, a risk factor for thrombus formation per Virchow’s triad. Immobility slows venous return, promoting clot development, making this choice counterproductive and incorrect for preventing postoperative thrombi.

Choice B reason: Light wrapping may provide comfort but does not effectively prevent thrombus formation. Compression stockings are preferred for venous return, and wrapping alone is insufficient, making this choice less effective than ambulation.

Choice C reason: Early ambulation promotes venous return, reducing stasis and preventing thrombus formation in postsurgical patients. It enhances circulation, countering Virchow’s triad, and is a standard intervention, making this the correct action to implement.

Choice D reason: Pillows under the knees cause venous pooling by flexing joints, increasing thrombus risk. This contradicts measures to enhance circulation, such as ambulation, making it an incorrect choice for thrombus prevention.

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Which of these enema orders would should the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home care nurse visits a new patient. The family asks how the home can be made safer. The nurse’s best advice includes which of the following?

Correct Answer is A

Explanation

Which action should the nurse implement to help prevent thrombus formation in postsurgical patients?

Correct Answer is C

Explanation

Which patient will the nurse see first?

A nurse is assessing a client’s wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?

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