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 A
Explanation
The correct answer is Choice A:
Assist in turning the client to one side. Choice A rationale:
When preparing a client with obstructive sleep apnea for sleep, the practical nurse (PN) should assist the client in turning to one side. This position is known as the lateral position and can be beneficial for clients with obstructive sleep apnea. Lying on one's side can help to reduce the likelihood of airway obstruction and minimize the occurrence of apnea (pauses in breathing) during sleep. This position promotes better airflow and can improve the client's overall sleep quality.
Choice B rationale:
Keeping oral suction equipment nearby (Choice B) might be appropriate for clients with respiratory issues or a risk of airway obstruction. However, it is not the best action for a client with obstructive sleep apnea. Sleep apnea primarily involves upper airway collapse, not excessive secretions or obstructions in the oral cavity.
Choice C rationale:
Offering to bring the client a sleeping pill (Choice C) is not an appropriate action for a client with obstructive sleep apnea. Sleep apnea is characterized by repeated episodes of blocked or restricted airflow during sleep. Sedative medications can further relax the muscles in the airway, worsening the condition and potentially leading to more severe apnea.
Choice D rationale:
Placing a cool air humidifier in the room (Choice D) may be helpful for clients who experience dryness or congestion in the airways during sleep. However, it is not specifically indicated for obstructive sleep apnea. While humidifiers can be beneficial for some sleep-related issues, they do not address the underlying cause of sleep apnea.
Correct Answer is D
Explanation
The correct answer is choiced. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
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