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.)
Insert lubricated tip of tubing 3 to 4 inches into the rectum.
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.
Clamping the enema administration tubing
Correct Answer : A,B,D,E
A. Inserting the lubricated tip of the tubing 3 to 4 inches into the rectum allows for the proper administration of the enema.
B. Positioning the client in the left lateral recumbent position helps expose the rectum for the enema administration.
C. Chilling the enema solution isn't recommended as it might cause discomfort or shock to the client.
D. Encouraging the client to retain the solution for at least 5 minutes helps ensure effectiveness.
E. Clamping the enema administration tubing after filling the enema bag helps control the flow during the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tell the UAP to take the client back to his room. - This action might not address the problem and may disrupt the ongoing activity without rectifying the situation.
B. Instruct the UAP to walk on the client's affected side. - When assisting a client with rightsided weakness, the caregiver should support the affected side, providing assistance and stability.
Instructing the UAP to walk on the client's affected side is the appropriate action.
C. Take over the ambulation and counsel the UAP later. - This might disrupt the ongoing care and might not rectify the situation immediately. Addressing it promptly is crucial.
D. Provide the client an assistive device, such as a cane or walker. - While assistive devices can be beneficial, in this scenario, the immediate concern is correcting the UAP's positioning
Correct Answer is A
Explanation
A. Encouraging the mother to use a one-piece pacifier is the appropriate action as it reduces the risk of choking or ingestion of small parts and is safer for the infant.
B. Observing the infant for difficulty in sucking is important, but addressing the safety of the pacifier takes precedence.
C. Informing the mother about potential dental problems associated with pacifier use might be relevant but doesn't address the immediate safety concern of the makeshift pacifier.
D. Complimenting the mother for meeting her infant's needs doesn't address the potential safety risks associated with the homemade pacifier.
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