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 A
Explanation
Choice A: cottage cheese has about 364 mg of sodium per 100 g, which is much higher than the other options.
Choice B: Broccoli is a generally healthy vegetable and does not need to be avoided solely for sodium intake unless heavily salted. Broccoli has only 33 mg of sodium per 100g.
Choice C: Ground sirloin has 75 mg of sodium per 100g which is much lower than that contained by cottage cheese.
Choice D: Bananas are a low-sodium food and do not need to be avoided for sodium intake.
Correct Answer is B
Explanation
Choice A: Sweaty palms may be related to various factors, including anxiety, physical activity, or environmental conditions. While it may warrant further assessment, it is not necessarily indicative of a nutritional issue in a professional dancer.
Choice B: Fatigue in a professional dancer can be a concerning issue and may indicate an underlying nutritional problem, such as inadequate calorie intake or nutrient deficiencies. Further assessment of the client's dietary habits and energy levels is warranted.
Choice C: Bunions are a foot deformity and are not directly related to nutritional assessment.
Choice D: Dry skin may be related to various factors, including environmental conditions and skin care practices. It may warrant assessment but is not necessarily indicative of a nutritional issue.
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