The nurse encounters resistance when inserting the tubing into a client's rectum for a
tap water enema. What action should the nurse implement?
Withdraw the tube and apply additional lubricant to the tube.
Encourage the client to bear down and continue to insert the tube.
Remove the tube and check the client for a fecal impaction.
Ask the client to relax and run a small amount of fluid into the rectum.
,Give this one a try later!
Ask the client to relax and run a small amount of fluid into the rectum.
If resistance is encountered during the initial insertion of an enema tube,
the client should be instructed to relax while a small amount of solution
runs through the tube into the rectum (D) to promote dilation. (A) is unlikely
to resolve the problem. (B) may cause injury. (C) should not be
implemented until other, less invasive actions, such as (D) have been taken.
A client is demonstrating a positive Chvostek's sign. What action should the nurse
take?
Observe the client's pupil size and response to light.
Ask the client about numbness or tingling in the hands.
Assess the client's serum potassium level.
Restrict dietary intake of calcium-rich foods.
Give this one a try later!
Ask the client about numbness or tingling in the hands.
A positive Chvostek's sign is an indication of hypocalcemia, so the client
should be assessed for the subjective symptoms of hypocalcemia, such as
numbness or tingling of the hands (B) or feet. (A and C) are unrelated
assessment data. (D) is contraindicated because the client is hypocalcemic
and needs additional dietary calcium.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related
to lack of motivation" for a client with Type 2 diabetes. Which finding supports this
nursing diagnosis?
Does not check capillary blood glucose as directed.
, Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Give this one a try later!
Eats anything and does not think diet makes a difference in health.
On admission, a client presents a signed living will that includes a Do Not Resuscitate
(DNR) prescription. When the client stops breathing, the nurse performs
cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal
issues could be brought against the nurse?
Assault.
Battery.
Malpractice.
False imprisonment.
Give this one a try later!
Battery.
Civil laws protect individual rights and include intentional torts, such as
assault (an intentional threat to engage in harmful contact with another) or
battery (unwanted touching).Performing any procedure against the client's
wishes can potentially create a legal issue, such as battery, even if the
procedure is of questionable benefit to the client.
tap water enema. What action should the nurse implement?
Withdraw the tube and apply additional lubricant to the tube.
Encourage the client to bear down and continue to insert the tube.
Remove the tube and check the client for a fecal impaction.
Ask the client to relax and run a small amount of fluid into the rectum.
,Give this one a try later!
Ask the client to relax and run a small amount of fluid into the rectum.
If resistance is encountered during the initial insertion of an enema tube,
the client should be instructed to relax while a small amount of solution
runs through the tube into the rectum (D) to promote dilation. (A) is unlikely
to resolve the problem. (B) may cause injury. (C) should not be
implemented until other, less invasive actions, such as (D) have been taken.
A client is demonstrating a positive Chvostek's sign. What action should the nurse
take?
Observe the client's pupil size and response to light.
Ask the client about numbness or tingling in the hands.
Assess the client's serum potassium level.
Restrict dietary intake of calcium-rich foods.
Give this one a try later!
Ask the client about numbness or tingling in the hands.
A positive Chvostek's sign is an indication of hypocalcemia, so the client
should be assessed for the subjective symptoms of hypocalcemia, such as
numbness or tingling of the hands (B) or feet. (A and C) are unrelated
assessment data. (D) is contraindicated because the client is hypocalcemic
and needs additional dietary calcium.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related
to lack of motivation" for a client with Type 2 diabetes. Which finding supports this
nursing diagnosis?
Does not check capillary blood glucose as directed.
, Occasionally forgets to take daily prescribed medication.
Cannot identify signs or symptoms of high and low blood glucose.
Eats anything and does not think diet makes a difference in health.
Give this one a try later!
Eats anything and does not think diet makes a difference in health.
On admission, a client presents a signed living will that includes a Do Not Resuscitate
(DNR) prescription. When the client stops breathing, the nurse performs
cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal
issues could be brought against the nurse?
Assault.
Battery.
Malpractice.
False imprisonment.
Give this one a try later!
Battery.
Civil laws protect individual rights and include intentional torts, such as
assault (an intentional threat to engage in harmful contact with another) or
battery (unwanted touching).Performing any procedure against the client's
wishes can potentially create a legal issue, such as battery, even if the
procedure is of questionable benefit to the client.
