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 D

Explanation

A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.

A. "MRSA is not that big of a deal." B. "I should wash my hands and encourage others who are around me to wash their hands." C. "I will no longer be able to transmit MRSA once my surgical site is completely healed." D. "My diet makes a difference in my ability to heal." E. "I should only take antibiotics until I feel better."

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

"MRSA is not that big of a deal."
No Understanding: MRSA is a serious infection that can be difficult to treat and can spread. It is important for the client to understand the severity of MRSA.
"I should wash my hands and encourage others who are around me to wash their hands."
Understanding: Hand hygiene is critical in preventing the spread of MRSA. The client is aware of the importance of hand washing for infection control.
"I will no longer be able to transmit MRSA once my surgical site is completely healed."
No Understanding: MRSA can be a persistent infection, and healing of the surgical site does not guarantee that MRSA cannot be transmitted. Proper infection control measures must continue.
"My diet makes a difference in my ability to heal."
Understanding: Nutrition plays a role in the healing process and overall recovery. A balanced diet supports the immune system and aids in wound healing.
"I should only take antibiotics until I feel better."
No Understanding: It is crucial to complete the full course of antibiotics as prescribed to ensure the infection is fully treated and to prevent resistance

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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

The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

Correct Answer is D

Explanation

Exhibits The practical nurse (PN) re-educates the client on methicillin-resistant Staphylococcus aureus (MRSA). Click to indicate whether the client's statement(s) indicate understanding or no understanding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?

The practical nurse (PN) is reviewing home care instructions with the mother of a young girl with a urinary tract infection (UTI). Which information reported by the mother demonstrates understanding of home care for the child?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. What client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? Select all that apply.

Exhibits Drag from statement options to complete the sentence. To assess outcomes, the practical nurse (PN) should consider information reported by the client and caregiver and focus on evaluating the client's dropdown and dropdown

The practical nurse (PN) views the mid-line episiotomy of a client who reports pain in her stitches. Which action should the PN take first?

Exhibits Review H and P and nurse's note. Which are the first four actions that the practical nurse (PN) should do?