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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Oranges are a good source of vitamin C, which is important for overall health, but they are not the primary dietary source for preventing rickets.
Choice B: Fortified milk is the best dietary source for preventing rickets because it is enriched with vitamin D, which is essential for calcium absorption and bone health. Vitamin D helps prevent rickets by promoting the absorption of calcium and phosphate in the body, which are necessary for proper bone development.
Choice C: Bananas are a good source of potassium but are not a primary dietary source for preventing rickets.
Choice D: Apple juice is not a primary dietary source for preventing rickets. While it may provide some vitamins and minerals, it is not directly associated with preventing this condition.
Correct Answer is A
Explanation
Choice A: The client's statement reflects an understanding of the DASH diet's emphasis on lean meats, nuts, and dried beans as protein sources, which aligns with the principles of the diet.
Choice B: The DASH diet encourages the consumption of more than 4 to 6 servings of fruits and vegetables daily.
Choice C: The DASH diet does not eliminate dairy-based products but recommends choosing low-fat or fat-free options.
Choice D: The DASH diet does not focus on gluten-free foods but rather on overall dietary patterns that promote heart-healthy eating.
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