Page 2611 - Saunders Comprehensive Review For NCLEX-RN

Priority Concepts: Clinical Judgment; Safety
Reference: Potter et al. (2017), pp. 1177-1178.

926. Answer: 1

Rationale: The enema is never administered while on a toilet due to safety. The
enema is administered while the client is in a left side-lying (Sims’) position with the
right knee flexed. This allows enema solution to flow downward by gravity along
the natural curve of the sigmoid colon and rectum. It is important for the client to
retain the fluid for as long as possible to promote peristalsis and defecation. If the
client complains of fullness or pain, the flow is stopped for 30 seconds and restarted
at a slower rate. The higher the solution container is held above the rectum, the
faster the flow and the greater the force in the rectum; this could increase cramping.
Test-Taking Strategy: Note the strategic words, need for further instruction. This
indicates a negative event query, and the need to select the option that is incorrect.
Eliminate options 3 and 4 first because they are comparable or alike. From the
remaining options, focusing on the subject, safety, will direct you to the correct
option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Skills: Elimination
Health Problem: N/A
Priority Concepts: Client Education; Elimination
Reference: Potter et al. (2017), pp. 1165, 1170-1171.

927. Answer: 4

Rationale: Negative reinforcement when the stimulus is produced is descriptive
of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.
Test-Taking Strategy: Note the strategic words, need for further teaching. These
words indicate a negative event query and ask you to select an option that is
incorrect. Think about the subject, self-control. This subject will assist you in
answering correctly.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Teaching and Learning
Content Area: Mental Health
Health Problem: Mental Health: Coping
Priority Concepts: Anxiety; Stress
Reference: Varcarolis (2017), p. 23.

928. Answer: 2, 4,5, 6

Rationale: The nurse should teach the client how to care for the stoma, depending
on the type of laryngectomy performed. Most interventions focus on protection of
the stoma and the prevention of infection. Interventions include obtaining a

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