Author Question: MC When administering an enema, the nurse follows which one of the following nursing actions? A. ... (Read 33 times)

Marty · **on:** Jul 24, 2018

MC When administering an enema, the nurse follows which one of the following nursing actions?

A. Warm the enema solution to 99F.
B. Insert the enema tube 68 inches into the rectum.
C. Instill 100200 mL solution slowly.
D. Raise the enema container to a height of 18 inches.

Question 2

When assessing a patient's tracheostomy site, the nurse notes redness and inflammation around the stoma. Which intervention can the nurse provide to address this problem?

a. Decrease the frequency of tracheostomy care.
b. Apply a dry gauze dressing just under the stoma.
c. Remove the ties at frequent intervals.
d. Apply a topical antibacterial solution and allow it to dry.

zhanghao · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

D

Answer to Question 2

D
Apply a topical antibacterial solution and allow it to dry. Increase the frequency of tracheostomy care. Apply a hydrocolloid or transparent dressing just under the stoma to protect the skin from breakdown. Consult with a skin care specialist. Adjust the ties or apply new ones when the ties are loose or tight. Never remove the ties.