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

The solution temperature should be determined by the client’s comfort level

The temperature of the enema is unrelated to the enema’s eﬀectiveness

The solution should approximate the client’s body temperature (98°F or 36°C).

The temperature should be higher (110°F or 43°C) than the client’s body temperature

Answer and Explanation

The Correct Answer is C

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
The temperature of the enema solution aﬀects the eﬀectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.

Option A is incorrect because the client’s comfort level may not reﬂect the optimal temperature for the

enema.

Option B is incorrect because the temperature of the enema does aﬀect its eﬀectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.

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Correct Answer is A

Explanation

a) Collect fingerstick glucose levels.Correct

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or ﬂuctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.

b) Implement bleeding precautions.

Implementing bleeding precautions is not the most important intervention for the PN to implement for a client who is receiving TPN. Bleeding precautions are measures to prevent or minimize bleeding in clients who have a high risk of hemorrhage due to conditions such as thrombocytopenia, coagulopathy, or anticoagulant therapy. TPN does not directly increase the risk of bleeding, although it may aﬀect the liver function and clotting factors in some cases². Therefore, bleeding precautions are not a priority for a client who is receiving TPN.

c) Obtain daily weights.

Obtaining daily weights is not the most important intervention for the PN to implement for a client who is receiving TPN. Obtaining daily weights is a way to monitor the client's ﬂuid balance, nutritional status, and response to therapy. TPN can cause ﬂuid overload, dehydration, or electrolyte imbalances in some cases²⁵. Therefore, obtaining daily weights is important, but not as important as monitoring glucose levels.

d) Check urine for albumin.

Checking urine for albumin is not the most important intervention for the PN to implement for a client who is receiving TPN. Checking urine for albumin is a way to detect proteinuria, which is an indicator of kidney damage or disease. TPN does not directly cause kidney problems, although it may aﬀect the renal function and urine output in some cases². Therefore, checking urine for albumin is not a priority for a client who is receiving TPN.

A. Mitral valve disease B. Asthma C. Nasal polyps D. Seasonal allergies

Correct Answer is B

Explanation

Choice A reason: Mitral valve disease is not a disorder that makes clients especially vulnerable to ozone effects because it is a condition that affects the heart valve that regulates blood flow between the left atrium and left ventricle, not the lungs or airways.

Choice B reason: Asthma is a disorder that makes clients especially vulnerable to ozone effects because it is a condition that causes inflammation, narrowing, and mucus production in the airways, which can worsen when exposed to ozone, a gas that irritates and damages lung tissuE.

Choice C reason: Nasal polyps are not a disorder that makes clients especially vulnerable to ozone effects because they are benign growths that occur in the lining of the nose or sinuses, not the lungs or airways.

Choice D reason: Seasonal allergies are not a disorder that makes clients especially vulnerable to ozone effects because they are immune system reactions to certain substances such as pollen or mold, not ozone, which is a chemical pollutant.

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

Nursing Test Bank

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