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. Ensuring minimal clutter reduces the risk of falls and injury due to potential bleeding episodes from ITP.
B. Monitoring blood cell laboratory values is important but doesn’t directly prevent physical injury.
C. Assessing for nerve pain or paralysis is essential for overall health but doesn't specifically prevent injury.
D. Evaluating neurological status after exercising is crucial but doesn't directly address the risk of physical injury associated with ITP.

A. A Observe how UAP obtains temperatures. B. B Return the thermometer for recalibration. C. C Show UAP how to chart temperatures, D. D Demonstrate how to use the equipment.

Correct Answer is A

Explanation

A. Observing the method of temperature measurement by the UAP helps identify any incorrect technique or error in obtaining readings.
B. Returning the thermometer for recalibration assumes the issue is with the equipment, which might not be the case.
C. Showing the UAP how to chart temperatures assumes the problem is with documentation, not measurement.
D. Demonstrating how to use the equipment might not address the specific error observed in temperature readings.

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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 female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

Correct Answer is A

Explanation

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?

Correct Answer is A

Explanation

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