An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

= The correct sequence is: A. Perform standard hand washing, B. Put on disposable gown, D. Don a pair of procedure gloves, C. Remove gloves and gown in the room.

Choice A rationale:

Performing standard hand washing before donning personal protective equipment (PPE) is essential to ensure that the UAP's hands are clean before putting on gloves and gown.

Choice B rationale:

Putting on a disposable gown is the next step after hand washing to protect the UAP's clothing from potential contamination.

Choice D rationale:

Donning a pair of procedure gloves is the next step after putting on the gown to protect the UAP's hands from contact with potentially infectious material.

Choice C rationale:

Removing gloves and gown in the client's room is the last step in the sequence. This step ensures that any potential contaminants stay within the isolation room and do not spread to other areas of the facility.

The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:

Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.

Choice B rationale:

Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.

Choice C rationale:

Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.

Choice D rationale:

Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.