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: Taking a prescribed analgesic an hour prior to breastfeeding can help alleviate the client's intense cramping while breastfeeding. This approach can provide effective pain relief.
Choice B: Changing the infant's position during the next feeding may or may not address the underlying cause of the client's intense cramping. Pain relief through medication is a more direct intervention.
Choice C: Drinking water before breastfeeding is important for hydration but may not directly address the cramping issue.
Choice D: Voiding and emptying the bladder before each feeding is a routine practice but is not specifically aimed at relieving cramping during breastfeeding.
Correct Answer is ["6"]
Explanation
To determine the volume of amoxicillin-clavulanic acid suspension to administer in a single dose, you can use the following calculation:
Dose prescribed: 300 mg Concentration available: 250 mg/5 mL
First, calculate the dose per mL:
Dose per mL = Concentration available (mg/mL) Dose per mL = 250 mg/5 mL
Dose per mL = 50 mg/mL
Now, calculate the mL needed for the prescribed dose:
Volume (mL) = Dose prescribed (mg) / Dose per mL Volume (mL) = 300 mg / 50 mg/mL
Volume (mL) = 6 mL
Therefore, the nurse should administer 6 mL of amoxicillin-clavulanic acid suspension in a single dose.
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