A primary care physician has ordered a high enema for a patient admitted for constipation. When administering the high enema, a nurse will
1. Insert the tip of the tubing a minimum of 8 inches to make certain that feces contained above the sigmoid colon will be removed.
2. Instill at least 1000 mL normal saline heated to 120°F to promote peristalsis but decrease the discomfort of cramping.
3. Insert the tip of the tubing 4 inches while the patient sits on the toilet to aid elimination by use of gravity.
4. Instill half of the ordered solution while the patient lies on the left side, then reposition the patient to supine and then right lateral side-lying position to instill the rest of the solution.
ANS: 4
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Helen Strauss, 81 years old, has had a CVA. The rehabilitation staff is very concerned about her insistence on doing everything herself and the resulting safety concerns. This behavior is typical of a
a. Left hemisphere CVA b. Right hemisphere CVA c. Cerebellar CVA d. Brainstem CVA
With regard to medications, herbs, shots, and other substances normally encountered, the maternity nurse should be aware that:
a. Both prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. b. The greatest danger of drug-caused developmental deficits in the fetus is seen in the final trimester. c. Killed-virus vaccines (e.g., tetanus) should not be given during pregnancy, but live-virus vaccines (e.g., measles) are permissible. d. No convincing evidence exists that secondhand smoke is potentially dangerous to the fetus.
The yearly amount an insured person must spend out-of-pocket for health care services before a health insurance policy will begin to pay its share is known as the
a. premium. b. deductible. c. copayment. d. coinsurance.
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices