The nurse prepares to administer a cleansing enema to a client with constipation

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ATI questions
When administering a cleansing enema the patient should be placed in the?
What procedure should be used to administer a cleansing enema?
When administering a cleansing enema the patient should be placed in the quizlet?
When preparing a client for an enema a nurse should help him into the?

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ATI questions

Question	Answer
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? A. Eating more protein is optimal prior to testing B. one stool specimen is sufficient for testing C. a red color change indicates a positive test D. the specimen cannot be contaminated with urine	D is correct. For fecal occult blood testing at home, the stool specimen cannot be contaminated with water or urine.
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni and cheese B. Fresh fruit and whole wheat toast C. Rice pudding and ripe bananas D. Roast chicken and white rice	B is correct. A high fiber diet promotes normal bowel elimination. The choice of fruit and toast is the highest fiber option.
A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? (select all that apply) __A. Bradycardia __B. Hypotension __C. Fever __D. Poor skin turgor __E. Peripheral edema	B. Prolonged diarrhea leads to dehydration, which causes a decrease in blood pressure C. Prolonged diarrhea leads to dehydration, which causes fevers D. Prolonged diarrhea leads to dehydration, which causes poor skin tugor
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? (select all that apply) __A. Warm the enema solution prior to instillation __B. Position the client on the left side with the right leg flexed forward __C. Lubricate the rectal tube or nozzle __D. Slowly insert the rectal tube about 2 inches __E. Hang the enema container 24 inches above the client's anus	A. the nurse should warm the enema solution because cold fluid can cause abdominal cramping and hot fluid can injure the intestinal mucosa B. This position allows a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon C. Lubrication prevents trauma or irritation to the rectal mucosa
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? A. Have the client hold his breath briefly B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container	D is correct. To relieve the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema solution container.
A nurse is explaining to a group of nursing students the various factors that alter bowel elimination patterns. List at least eight factors that affect bowel elimination.	Age, diet, Fluid intake, physical activity, psychosocial factors, personal habits, positioning, pain, pregnancy, surgery and anesthesia, medications
-A nurse in a provider's office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the client's incontinence? (select all that apply) __A. Limit total daily fluid intake __B. Decrease or avoid caffeine __C. Increase the intake of calcium supplements __D. Avoid alcohol	B. Caffeine is a bladder irritant and can worsen stress incontinence D. Alcohol is a bladder irritant and can worsen stress incontinence
A client who has indwelling catheter reports a need to urinate. Which of the following interventions should the nurse perform? A. Check to see whether the catheter is patent (clogged or kinked) B. Reassure the client that it is not possible for her to urinate C. Re catheterize the bladder with a larger gauge catheter D. collect a urine specimen for analysis	A is correct. A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate
A provider prescribes a 24 hr urine collection for a client. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep all voidings in a container at room temperature C. Ask the client to urinate and pour into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container	A is correct. The nurse should discard the first voiding of the 24 hr urine specimen, and note the time
A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? (select all that apply) __A. establish a schedule of voiding prior to meal times __B. have the client record voiding times __C. Gradually increase the voiding intervals __D. Remind client to hold urine until next scheduled voiding time __E. provide a sterile container for voiding	B. Asking the client to keep track of voiding times is an appropriate nursing action C. Gradually increasing the voiding interval is an appropriate nursing action D. The client should be reminded to hold urine until the next scheduled voiding time
A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections (UTIs) with a group of assistive personnel. Which of the following should be included in the review? (select all that apply) __A. having sexual intercourse on a frequent basis __B. lowering of testosterone levels __C. wiping for front to back __D. the location of the vagina in relation to the anus __E. undergoing frequent catheterization	A. Having sexual intercourse on a frequent basis is a factor that increases the risk of UTIs in both males and females E. Undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. That should help!"	B is correct. Showing interest in the client is applying the therapeutic communication technique of offering self; asking more about how the client feels is applying the therapeutic communication technique of encouraging a description of perception
A nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at high risk for body image disturbances? (select all that supply) __A. 30 year old male following laparoscopic appendectomy __B. 45 year old female following a mastectomy __C. 20 year old female following left above the knee amputation __D. 65 year old male following cardiac catheterization __E. 55 year old male following stroke with right sided hemiplegia	B. Having a mastectomy involves a change in the physical appearance of a women and can lead to body image disturbances related to femininity and sexuality C. Having an above the knee amputation involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength E. Having a right sided hemiplegia involves a change in physical appearance and can lead to body image disturbances related to function, heath, and strength
A nurse is caring for a client who is 3 days postoperative following a below the knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost his leg." D. "I don't even want to look at my leg. You can check the dressing."	D is correct. Refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated. This would imply a distorted body image.
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterizartion. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements is an appropriate response by the nurse? A. "sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "OH, I wouldn't be to concerned.	B is correct. The nurse is acknowledging and allowing the client to discuss his concerns regarding sexual functioning
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help." B. "I'll never be able to care for this at home. Can't you just send nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things." D. "It may take me a while to get this."	B is correct. This client is displaying a lack of interest in learning how to care for the colostomy and depends on others to care for him. The nurse should suspect issues with self concept with this client.
A nurse is using an interpreter to communicate with a client. Which of the following are appropriate when communicating with a client and his family? (select all that apply) __A. Talk to the interpreter about the family while the family is in the room. __B. Ask the family one question at a time. __C. Look at the interpreter when asking the family questions. __D. Use lay terms if possible __E. Do not interrupt the interpreter and the family as they talk.	B. Asking the family one question at a time will promote effective communication between the family and the nurse/interpreter. D. Using lay terms will promote effective communication between the family and the nurse/interpreter. E. Not interrupting will promote effective communication between the family and the nurse/interpreter
A nurse is caring for a client who shares the same religious background. The nurse should recognize that A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another C. The same religious beliefs may influence individuals differently. D. They should discuss the differences and commonalities in their belief	C is correct. Members of any particular religion should be assessed for individual feelings and ideas
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions is appropriate for the nurse to take? A. Contact the hospitals spiritual services. B. Ask him what is making him cry. C. Provide quiet times for these moments. D. Turn on the television for a distraction.	C is correct. Providing privacy and time for the reading of religious materials supports the client's spiritual health
A nurse is planning care for a client who is devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client? A. "I will make sure the menu includes kosher options." B. "I will discuss the daily schedule with the client to make sure the client to make sure the client will have time for prayer." C.I will use direct eye contact	B is correct. Devout Muslims pray five times a day. Without proper awareness and planning, the client may refuse necessary treatments such as physical therapy if adequate pray times are not planned for and incorporated into the client's day
A nurse is taking care of a Jehovah's witness and a blood transfusion is essential for this client. The client tells the nurse that based on his religious values and mandates, he cannot receive the transfusion. Which response from the nurse is appropriate? A. "Why does your religion mandate that you cannot receive any blood transfusions?" B. "Let's discuss the necessity for a blood transfusion with you religious and spiritual leaders and come to a reasonable solution."	B is correct. Involving the client's religious and spiritual leaders is a culturally responsive action at this point. Alternative forms of blood products can be discussed, and a plan acceptable to all can be reached.
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscle/promote healing. B. The client needs to be given privacy at times for self reflecting and organizing her life. C. The client's sense of loss can be lessened through retaining control of certain areas of her life	C is correct. Allowing the client as much control possible maintains dignity and self esteem.
A nurse is caring for a client who has stage 4 lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kubler-Ross 5 stages of Grief, which stage is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance	C is correct. The client is displaying bargaining by attempting to negotiate more time to live to see his daughter get married.
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (select all that apply) __A. Would you like me to contact the chaplain to come speak with you?" __B. "you will feel better soon. You have been expecting this for a while not." __C. "Tell me more about how you are feeling"	A and C are correct. Others correct answers will include "You know, it is quite normal to feel anger toward your husband at this time"
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what are anticipated clinical findings at this time. Which of the following is an appropriate response by the nurse? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone	D is correct. Muscle relaxation is an expected finding when a client is approaching death
A nurse is assisting a new nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the new nurse indicates an understanding of the procedure? (select all that apply) __A."I will remove the dentures from the body" __B. "I will make sure the body is lying completely flat" __C. "I will apply fresh linens and place a clean gown of the body" __D. "I will remove all equipment from the bedside" __E. "I will dim the lights in the room"	C. The body and the environment should be as clean as possible. This includes washing soiled areas of the body and applying fresh linens and a clean gown. D. The environment should be as clutter free as possible. All equipment and supplies should be removed from the bedside. E. Dimming the lights helps to provide a calm environment for the family
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (select all that apply) __A. speak fast and loudly __B. minimize background noise __C. Write down what the client does not understand __D. Allow plenty of time for the client to respond __E. use brief sentences with simple words	B,C,D,E
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment B. Put the client in a room with a client who is hearing impaired C. Provide a private room, and limit stimulation D. Talk loudly to the client, and encourage ambulation	C
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply) __A. Weber test showing lateralization to the right ear __B. Light reflex at 10 o'clock in the left ear __C. No signs of obstruction in the left ear canal __D. Rinne test showing length of time is decreased for air and bone conduction __E. Rinne test showing air conduction less than bone conduction in the left ear	A,C,D
A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids" B. "I clean the ear molds of my hearing aids with rubbing alcohol" C. "I keep the volume of my hearing aids turned up so I can hear better" D. "I take the batteries out of my hearing aids when I take them off at night"	D
A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the client's medication history, which of the following medications the client takes should alert the nurse to a further risk for ototoxity? (select all that apply) __A. Furosemide (Lasix) __B. Ibuprofen (Advil) __C. Cimetidine (Tagamet) __D. Simvastatin (Zocor) __E. Amiodarone (Cordarone)	B,C,D,E

When administering a cleansing enema the patient should be placed in the?

The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon.

What procedure should be used to administer a cleansing enema?

Remove the cap from the nozzle of the enema. Gently insert the tip of the nozzle into the anus, and continue inserting it 10 centimeters (3–4 inches) into the rectum. Slowly squeeze the liquid from the container until it is empty, then gently remove the nozzle from the rectum. Wait for the enema to take effect.

When administering a cleansing enema the patient should be placed in the quizlet?

Place the patient in the dorsal recumbent position on a bedpan. at least 30 min, but preferably as long as he can.

When preparing a client for an enema a nurse should help him into the?

Which steps should the nurse take when administering an enema? 1. Assist the client into the left-lateral Sims' position., 2.

The nurse prepares to administer a cleansing enema to a client with constipation

ATI questions

When administering a cleansing enema the patient should be placed in the?

What procedure should be used to administer a cleansing enema?

When administering a cleansing enema the patient should be placed in the quizlet?

When preparing a client for an enema a nurse should help him into the?

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