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. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.
B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.
C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.
D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.
Correct Answer is D
Explanation
Rationale:
A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.
C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.
D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.