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

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

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

Correct answer: C

Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.

2. A client with type 2 diabetes mellitus is scheduled for an arteriogram. Which of the following medications should the nurse instruct the client to discontinue 48 hours prior to the procedure?

Correct answer: D

Rationale: The correct answer is D, Metformin. Metformin should be discontinued 48 hours before an arteriogram due to the risk of lactic acidosis. Atorvastatin (Choice A) is a statin used to lower cholesterol levels and is not typically contraindicated before an arteriogram. Digoxin (Choice B) is a medication used for heart conditions and does not need to be discontinued before an arteriogram. Nifedipine (Choice C) is a calcium channel blocker used to treat high blood pressure and angina, and it is not necessary to discontinue before the procedure.

3. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

4. A client with osteoporosis is being taught by a nurse how to prevent further bone loss. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Perform weight-bearing exercises. Weight-bearing exercises are essential for preventing further bone loss and improving bone density in clients with osteoporosis. Calcium supplements alone may not be sufficient to prevent bone loss without adequate physical activity. Option C, 'Avoid weight-bearing exercises,' is incorrect as these exercises are beneficial for bone health. Option D, 'Limit intake of high-phosphorus foods,' is not directly related to preventing further bone loss in osteoporosis.

5. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.

Similar Questions

A client is experiencing a panic attack. Which of the following actions should the nurse take first?
A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following actions should the nurse implement?
How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?
A nurse is teaching a client who has a new prescription for iron supplements. Which of the following statements by the client indicates an understanding of the teaching?
What is the most appropriate action when a patient experiences chest pain?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses