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 D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
Correct Answer is D
Explanation
Rationale:
A. Providing a back rub can be done by an AP, as it does not require specialized nursing skills.
B. Transporting a client is an appropriate task for an AP if the client is stable.
C. Performing oral hygiene for a postoperative client can be managed by an AP with supervision.
D. Removing and cleaning the cannula of a new tracheostomy requires specific skills and knowledge that only a licensed nurse should perform to avoid complications.