The practical nurse (PN) is administering a saline enema to a client who was admitted
because of a fever of unknown origin and is now constipated. Which techniques should
the PN use? (Select all that apply.)

Position client in left lateral recumbent position to expose buttocks.

Chill the enema solution to help reduce the client's fever.

Encourage client to retain solution for at least 5 minutes.

Insert lubricated tip of tubing 3 to 4 inches into the rectum.

Answer and Explanation

Correct Answer : A,C,D

Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.

Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.

Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.

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Correct Answer is B

Explanation

Choice A: Teaching clients about the potential side effects of antipsychotic drugs is important, but it is not the most critical aspect of medication administration policy. Monitoring for side effects and adverse reactions is typically the responsibility of healthcare providers and nursing staff.

Choice B: Monitoring all clients receiving antipsychotic drugs for indications of tardive dyskinesia is a crucial standard to include in the policy. Tardive dyskinesia is a serious side effect associated with long-term use of antipsychotic medications, and early detection and intervention are essential to prevent its progression.

Choice C: Ensuring that all clients treated with antipsychotic drugs receive prompt renewals as needed is important for continuity of care, but it is not the primary focus of a policy for administering antipsychotic medications.

Choice D: Documenting all client therapeutic serum levels related to antipsychotic medications is relevant but may not apply to all clients receiving these medications. Monitoring for side effects and adverse reactions is generally more universally applicable and critical to patient safety.

A. Check mental acuity. B. Measure urinary output. C. Inspect for sacral edema. D. Auscultate all lung fields.

Correct Answer is D

Explanation

Choice A: Checking mental acuity is important for assessing the client's cognitive function, but it may not be the most crucial intervention in the context of left- sided heart failure.

Choice B: Measuring urinary output is a valuable assessment in clients with heart failure, but it is not the most important intervention among the choices provided.

Choice C: Inspecting for sacral edema is a relevant assessment for clients with heart failure, especially when assessing for fluid retention. However, it may not be the highest priority in this case.

Choice D: Auscultating all lung fields is the most important intervention for a client with left-sided heart failure. Left-sided heart failure often results in pulmonary congestion, and auscultating the lung fields can provide critical information about the presence of crackles, wheezes, or other abnormal breath sounds, indicating worsening heart failure.

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The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?

Correct Answer is B

Explanation

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

Correct Answer is D

Explanation

A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?

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The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

The practical nurse (PN) is administering a saline enema to a client who was admitted
because of a fever of unknown origin and is now constipated. Which techniques should
the PN use? (Select all that apply.)