A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

cool the solution to 65 degrees F

boil the solution and let it cool down.

warm the solution to body temperature

warm the solution in the microwave.

Answer and Explanation

The Correct Answer is C

Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.

Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.

Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.

Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.

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Correct Answer is A

No explanation

A. Blood pressure increases from 110/84 to 118/88 mm Hg. B. Temperature increases from 98.8°F to 99.0°F. C. Pulse rate decreases from 78 to 52 beats/min. D. Respiratory rate increases from 16 to 24 breaths/min.

Correct Answer is C

Explanation

Choice A This change in blood pressure is not alarming and does not require immediate cessation of the procedure.

Choice B A slight increase in temperature is within a normal range and does not indicate an urgent issue related to the stool removal procedure.

Choice C A significant decrease in pulse rate suggests bradycardia, which can be a serious sign and might be caused by the stimulation of the vagus nerve during the procedure. The nurse should stop immediately and take corrective action.

Choice D An increase in respiratory rate may indicate increased anxiety or discomfort, but it is not an immediate cause for stopping the procedure.

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A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission physical assessment, a nurse questions a patient about their bowel elimination pattern. The nurse may say, "Can you tell me your bowel regimen? Do you have a regular, bowel movement every day? What is the approximate time that you have a bowel movement?" The nurse's goal is

Correct Answer is A

A nurse is digitally removing stool that is impacted from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:

Correct Answer is C

Explanation

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