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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "May I sit with you for a while?" - This response offers companionship and emotional support without pushing the resident to engage in an activity or prying into his feelings. It respects his desire for solitude while providing the option for company if he wishes.
B. "Why do you want to stay in your room today?" - This might be perceived as intrusive and pushy, potentially making the resident more withdrawn.
C. "Come into the recreation area. We have your favorite card game and I will play it with you." - While well-intentioned, this suggestion may not align with the resident's current emotional state or desire for solitude.
D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." - This response acknowledges the resident's feelings but may not address his immediate need for companionship or support.

A. When all wounds are closed, complete recovery has been achieved. B. Full recovery means performing all activities of daily living independently. C. Recovery attainment is when one's highest level of functioning is achieved. D. Continuous rehabilitation will be required for the rest of a life time.

Correct Answer is C

Explanation

A. When all wounds are closed, complete recovery has been achieved. - Closure of wounds is an important part of recovery but might not encompass the entirety of rehabilitation goals.
B. Full recovery means performing all activities of daily living independently. - While important, full recovery might not necessarily imply independence in all activities.
C. Recovery attainment is when one's highest level of functioning is achieved. - This statement best reflects the goal of rehabilitation after a burn injury, aiming for the client to achieve the highest level of functional ability possible.
D. Continuous rehabilitation will be required for the rest of a lifetime. - While some individuals might need ongoing support, it's not the primary focus of the rehabilitation goal.

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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.)

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Naxlex Comprehensive Predictor Exams

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is A

Explanation

Which client statement indicates to the practical nurse (PN) that the client understands the goal of the rehabilitation plan of care following a burn injury?

Correct Answer is C

Explanation

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)

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A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPS needs additional information about the turning procedure?

The practical nurse (PN) is charting vital signs on a hand-written flow sheet and realizes that an error has been made. What should the PN do to rectify this error?