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","C"]
Explanation
A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.
Correct Answer is D
Explanation
A. Administer a PRN antianxiety agent. - This should be a last resort due to potential side effects.
Non-pharmacological interventions are usually preferable.
B. Tell her no one is behind the curtain. - Arguing or contradicting her belief may escalate her agitation or confusion.
C. Transfer the client to another room. - Moving her to a new environment might exacerbate her confusion and distress.
D. Leave a night light on in her room. - This is a simple, non-intrusive intervention that can help reduce visual misinterpretations and provide comfort, potentially calming her agitation without confrontation or disruption.
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