An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?
The solution should approximate the client's body temperature (98°F or 36°C).
The temperature of the enema is unrelated to the enema's effectiveness.
The solution temperature should be determined by the client's comfort level.
The temperature should be higher (110°F or 43°C) than the client's body temperature.
The Correct Answer is A
The correct answer is Choice A:
The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:
The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.
Choice B rationale:
This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.
Choice C rationale:
This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.
Choice D rationale:
This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Crushing the medication and administering it in applesauce might alter its pharmacokinetics, rendering it ineffective or causing it to act too quickly. Sublingual tablets are designed to dissolve under the tongue for rapid absorption into the bloodstream. Crushing the tablet and mixing it with applesauce could change its intended mode of action.
Choice B rationale:
Placing the tablet under the client's tongue is the correct action for a sublingual tablet. Sublingual administration allows the medication to dissolve directly into the bloodstream through the sublingual mucosa, bypassing the digestive system and providing rapid onset of action.
Choice C rationale:
Obtaining a liquid form of the medication might be an option, but it may not always be available. Additionally, some medications are not available in liquid forms, and the liquid form might have a slower onset of action compared to the sublingual route.
Choice D rationale:
Placing the tablet inside the client's cheek is known as the buccal route of administration. While this route is also for oral absorption, sublingual administration is preferred for specific medications designed for rapid absorption.
Correct Answer is C
Explanation
Choice A rationale: Enrollment in a remedial education class is unnecessary because the UAP is currently demonstrating the correct, evidence-based technique for providing oral care to an unconscious client to prevent aspiration.
Choice B rationale: While positive reinforcement is beneficial, the primary focus should be on the clinical safety of the procedure. Encouraging family participation is secondary to ensuring the UAP maintains proper safety protocols.
Choice C rationale: The side-lying position, combined with a towel and basin under the chin, allows secretions to drain out of the mouth by gravity. This is the safest position to prevent aspiration.
Choice D rationale: Placing an unconscious client in Fowler's position increases the risk of the tongue falling back and secretions being aspirated into the lungs. The flat, side-lying position is much safer.
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