A patient who is constipated has just received a mineral oil-retention enema. The nurse encourages this patient to hold this enema for a minimum of how long?
5 minutes
60 minutes
1 minutes
15 minutes
The Correct Answer is D
When a patient receives a mineral oil-retention enema for constipation, it is important for them to hold the enema for at least 15 minutes to allow the mineral oil to soften the stool and facilitate its passage. During this time, the patient should try to resist the urge to defecate and retain the enema solution in the rectum for the desired effect.
Holding the enema for just 5 minutes (option A) may not provide sufficient time for the mineral oil to have an optimal effect on softening the stool.
Holding the enema for 60 minutes (option B) is incorrect because is not typically necessary and may cause discomfort or inconvenience to the patient. Most mineral oil-retention enemas do not require such a long duration of retention.
Holding the enema for just 1 minute (option C) is incorrect because is too short a duration for the mineral oil to have any significant effect on softening the stool.
It is important for the nurse to provide specific instructions to the patient regarding the duration of enema retention and ensure the patient understands the importance of following these instructions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In this situation, the nurse's priority should be addressing the patient's anxiety and fear. The patient has expressed their fear and it is important for the nurse to provide emotional support and reassurance. By acknowledging the patient's fear and addressing it, the nurse can help alleviate anxiety and promote a sense of calmness before the surgery.
Assessing bowel sounds and the presence of gas (option B) is incorrect because it is only important in preoperative assessment. Addressing the patient's anxiety should take precedence as it directly affects the patient's emotional well-being.
The family's questions about the procedure (option C) is incorrect because it can only be addressed after attending to the patient's immediate emotional needs.
Assessing lung sounds and respiratory rate (option D) is incorrect because it is not the immediate priority in this scenario. Addressing the patient's anxiety should take precedence over respiratory assessment unless there are specific indications suggesting a respiratory issue.
Correct Answer is D
Explanation
Cleaning the area around a colostomy stoma with mild soap and water is the recommended method. This helps to effectively remove any debris, residue, or stool around the stoma while being gentle on the skin. It is important to use a mild, non-irritating soap and lukewarm water.
Option A, cleaning with alcohol swab and letting it air dry, is not recommended as alcohol can be drying and irritating to the skin around the stoma.
Option B, cleaning with tap water, may not be sufficient to remove debris or bacteria effectively. Mild soap is needed to ensure proper cleaning.
Option C, cleaning with iodine only, is not recommended as iodine may be too harsh and can irritate the skin.
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