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 A

Explanation

A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.

A. Cheese products. B. Egg white products. C. Soybean products. D. Shellfish products.

Correct Answer is C

Explanation

Choice A: Cheese products are not part of a vegan diet as they come from animal sources (dairy).

Choice B: Egg white products are also not part of a vegan diet as they come from animal sources (eggs).

Choice C: Soybean products, such as tofu and tempeh, are commonly recommended for vegans to enhance their nutritional intake. These products are rich in protein, calcium, and other nutrients and can be used as meat or dairy substitutes in various recipes.

Choice D: Shellfish products are not part of a vegan diet as they come from animal sources (shellfish).

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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

During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

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.)