An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?
The solution should approximate the client's body temperature (98°F or 36°C).
The temperature of the enema is unrelated to the enema's effectiveness.
The solution temperature should be determined by the client's comfort level.
The temperature should be higher (110°F or 43°C) than the client's body temperature.
The Correct Answer is A
The correct answer is Choice A:
The solution should approximate the client's body temperature (98°F or 36°C). Choice A rationale:
The ideal temperature for administering an oil retention enema is to approximate the client's body temperature. Using a solution at the client's body temperature helps to prevent discomfort and potential injury to the rectal mucosa. The temperature of 98°F (36°C) is considered safe and comfortable for the client.
Choice B rationale:
This option is incorrect because the temperature of the enema solution does matter. Administering an enema that is too cold or too hot can cause discomfort, cramping, and potential damage to the rectal tissue.
Choice C rationale:
This option is not the best choice because relying solely on the client's comfort level may not ensure the optimal temperature for the enema solution. The client's perception of comfort can vary, and it may not necessarily reflect the ideal temperature for administration.
Choice D rationale:
This option is incorrect because using a temperature higher than the client's body temperature, such as 110°F (43°C), can be harmful and increase the risk of burns or injury to the rectal lining.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C:
Suggest that an increase in fruits and vegetables is more beneficial.
Choice C rationale:
While dairy products do provide essential nutrients like calcium and vitamin D, there is no strong evidence to suggest that increasing dairy intake alone will significantly reduce the risk of cancer. On the other hand, fruits and vegetables are known to be rich in antioxidants and phytochemicals that have been associated with a reduced risk of cancer. Therefore, suggesting an increase in fruits and vegetables is a more evidence-based approach to reducing cancer risk.
Choice A rationale:
Encouraging exercise is a good recommendation for overall health, but it does not directly address the client's concern about reducing cancer risk. Focusing on a balanced diet, including plenty of fruits and vegetables, is more relevant to the client's specific concern.
Choice B rationale:
Reminding the client about Vitamin D-fortified dairy products may be helpful for addressing Vitamin D intake, but it doesn't necessarily address the broader concern of reducing cancer risk. Moreover, the link between dairy and cancer risk reduction is not as well-established as the benefits of fruits and vegetables.
Choice D rationale:
Providing information about cancer warning signs is important for cancer awareness but doesn't address the client's current dietary choices and concerns about cancer prevention. The focus should be on evidence-based dietary recommendations to reduce cancer risk.
Correct Answer is C
Explanation
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D.Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
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