a nurse is preparing to administer an enema to a 64 year old client which of the following actions of the nurse is most appropriate

NCLEX-RN

NCLEX RN Exam Prep

1. A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?

A. Assist the client to lie in the semi-Fowler position
B. Apply lubricating jelly to the tip of the catheter before insertion
C. Instill a total of 30cc of fluid into the client's rectum
D. Ask the client to hold the solution in for 30 seconds

Correct answer: B

Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.

2. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?

A. Will comply with the treatment prescribed.
B. Has given up her belief in naturalistic causes of disease.
C. May also be seeking the assistance of a shaman or medicine man.
D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

Correct answer: C

Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.

3. The Atlas and the Axis are:

A. found in the vertebrae.
B. described as being cervical.
C. the first two bones that form the column for the spine on the superior aspect.
D. All of the above.

Correct answer: D

Rationale: The Atlas and the Axis are the first two cervical vertebrae, designated as C1 and C2. The Atlas (C1) supports the skull, while the Axis (C2) allows for rotation of the skull. Therefore, all the statements in choices A, B, and C are correct, making 'All of the above' the correct answer. Choice A is correct as the Atlas and Axis are indeed found in the vertebrae. Choice B is correct as they are the first two cervical vertebrae. Choice C is correct as these bones form the superior aspect of the spine.

4. In a 68-year-old man, a gradual loss of hearing is known as _____________.

A. presbycusis
B. xerostomia
C. myopia
D. presbyopia

Correct answer: A

Rationale: The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.

5. When counting an infant's respirations, which technique is correct?

A. Watching the chest rise and fall
B. Observing the movement of the abdomen
C. Placing a hand across the infant's chest
D. Using a stethoscope to listen to the breath sounds

Correct answer: B

Rationale: The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.