Which statement is correct regarding administration of a cleansing enema to an adult?
a. The temperature of the water should be 115 degrees Fahrenheit.
b. The enema container should be held 24 inches above the anal opening.
c. Insert the catheter 8 to 10 inches above the anal opening.
d. If the patient complains of cramping, stop the flow until the feeling passes.
D
Enemas administered to adults should be at the temperature of 105 to 110 degrees F. The rectal tube should be inserted approximately 2 to 4 inches (7 to 10 cm). The solution should be held at 12 to 18 inches above the rectum. The enema should be administered slowly with momentary pauses to decrease the incidence of intestinal spasms and cramping.
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What is the most appropriate nursing diagnosis for a patient who has had nose surgery?
a. Risk for imbalanced body temperature b. Social isolation c. Decreased cardiac output d. Risk for activity intolerance
A patient with stable exertional angina has been receiving a beta blocker. Before giving the drug, the nurse notes a resting heart rate of 55 beats per minute. Which is an appropriate nursing ac-tion?
a. Administer the drug as ordered, because this is a desired effect. b. Withhold the dose and notify the provider of the heart rate. c. Request an order for a lower dose of the medication. d. Request an order to change to another an-tianginal medication.
A patient is taking warfarin (Coumadin) daily
to prevent blood clots from forming in deep veins. Which statement made by the patient indicates that more teaching is needed about this therapy? a. "I have been eating more salads and other green, leafy vegetables to prevent constipation." b. "I have been using acetaminophen (Tylenol) instead of aspirin for pain." c. "Instead of a safety razor, I have been using an electric shaver." d. "On hot days, I make sure to drink at least two quarts of water."
What are potential causes of performance inadequacies?
a. The person to whom the task was assigned had appropriate educational qualifications to complete the task. b. The task was assigned to a person capable of carrying out the assignment. c. The person who delegated the task con-firmed the recipient's ability to perform the task. d. The person to whom the task was assigned did not understand what the task involved.