a nurse is preparing to administer a cleansing enema to a client which of the following actions should the nurse plan to take
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Nursing Elites

ATI LPN

LPN Fundamentals Practice Questions

1. A healthcare professional is preparing to administer a cleansing enema to a client. Which of the following actions should the healthcare professional plan to take?

Correct answer: C

Rationale: Positioning the client on their left side is crucial when administering an enema as it helps facilitate the flow of the solution into the sigmoid and descending colon. This position allows gravity to assist in the process. Placing the client on the left side is a standard practice to promote optimal outcomes during the procedure. Choices A, B, and D are incorrect. Choice A provides a specific measurement for the insertion depth of the rectal tube, which is not typically necessary to include in the plan of action. Choice B is essential but not specific to enema administration. Choice D mentions holding the solution bag without specifying the correct height, which should typically be around 18-24 inches above the rectum for a cleansing enema.

2. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?

Correct answer: A

Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.

3. A client has a new diagnosis of hypertension, and the nurse is teaching them about the DASH diet. Which of the following statements should the nurse include in the teaching?

Correct answer: C

Rationale: The DASH diet, recommended for managing hypertension, emphasizes increasing the intake of fruits and vegetables. These food groups are rich in essential nutrients, fiber, and antioxidants, which can help lower blood pressure levels and promote overall cardiovascular health.

4. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

5. When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?

Correct answer: B

Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.

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