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 A
Explanation
Rationale:
A. Cooperating involves finding a solution that satisfies both parties, as seen in allowing the nurses to go to lunch together while managing their clients.
B. Compromising would involve both parties giving up something to reach a middle ground, which is not exactly what is described.
C. Avoiding would mean not addressing the conflict directly, which is not the case here.
D. Competing involves asserting one’s own position at the expense of others, which does not align with the actions described.
Correct Answer is A
Explanation
Rationale:
A. The physiologic status of the clients is the most critical factor in assigning tasks, ensuring that clients with more complex needs receive appropriate care.
B. Social relationships are secondary to patient safety and quality of care.
C. Personal comfort level should not influence assignment decisions; patient care needs are the priority.
D. Assigning the most experienced nurse to complex clients is appropriate, but it should be based on client needs rather than just experience alone.