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. "Use wool blankets on your bed" is not recommended as wool is a flammable material that can pose a risk with oxygen use.
B. "Store unused oxygen tanks horizontally" is not correct; tanks should be stored upright to prevent damage or leakage.
C. "Check your oxygen equipment once each week" is insufficient; equipment should be checked more frequently to ensure safety.
D. "Do not adjust the oxygen flow rate" is correct as clients should not make adjustments without medical advice to ensure proper oxygen levels are maintained.
Correct Answer is A
Explanation
Rationale:
A. "The client must provide permission to share the records with you." is the correct procedure as medical records are confidential and require patient consent for release to family members.
B. I will ask the nursing supervisor to obtain the medical records for you is not correct unless the client has given permission.
C. The health care provider will share this information with you does not address the need for patient consent.
D. The ethics committee will need to approve this request for you is not apptlicable; consent from the client is required.