When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

Re-lubricate the tubing and re-insert it.

Insert the tubing an additional three inches into the rectum.

Raise the saline container six inches higher.

Instruct the client to take several slow, deep breaths.

Answer and Explanation

The Correct Answer is B

A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.

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Correct Answer is B

Explanation

A. Understanding that prostate cancer mostly affects older men reflects awareness but does not necessarily indicate acceptance of the prognosis.
B. Expressing that the client has found support from faith and family and rejecting negative outlooks shows a level of emotional acceptance and coping with the reality of advanced cancer.
C. Believing that the disease was undetected for a long time suggests denial or frustration rather than acceptance of the prognosis.
D. A desire to try every possible treatment reflects hope and possibly denial rather than acceptance of the prognosis.

A. Administer the medication at least 30 minutes prior to the client's meals. B. Ensure peak and trough serum levels are collected with the third dose of medication. C. Observe the client for development of involuntary movements of the lips and tongue. D. Assess the skin daily for areas of ecchymosis or other signs of bleeding.

Correct Answer is D

Explanation

A. Administering ketorolac does not require specific timing in relation to meals. It can be given with or without food, but the key considerations are related to the drug’s effects rather than meal timing.
B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
D. Assessing the skin daily for signs of bleeding is crucial because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding due to its effects on platelet function and gastrointestinal mucosa.

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When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

Correct Answer is B

Explanation

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

Correct Answer is D

Explanation

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