A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
Check the client's medical record for the provider's prescription.
Inform the charge nurse that the client refused the enema.
Explain to the client that the provider prescribed the procedure.
Assure the client that enemas are commonly prescribed for constipation.
The Correct Answer is A
Rationale:
A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.
B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.
C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.
D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.
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Correct Answer is B
Explanation
Rationale:
A. Asking other staff nurses does not address the immediate concern of the client and could lead to gossip or unnecessary complications.
B. Addressing the concern with the specific staff nurse directly is appropriate to understand any issues and to see if there is a valid reason for the client’s request.
C. Recommending transfer without understanding the issue could be premature and might not address the root of the problem.
D. Notifying human resources is a step that may be needed later but should not be the first action; the manager should first address the issue with the staff nurse.
Correct Answer is C
Explanation
Rationale:
A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.
B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.
C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.
D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.