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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C - IV infusion site is infiltrated. Choice A rationale:
The client reports feeling nauseous. While this symptom should be monitored, it is not the most crucial finding to report for a client in Addison's crisis. Nausea can be a common symptom during various medical conditions and may not warrant immediate action.
Choice B rationale:
Has not voided in four hours. While monitoring urine output is important, it may not be the most critical finding in Addison's crisis. Other symptoms like electrolyte imbalances and
circulatory collapse is more concerning in this scenario.
Choice C rationale:
IV infusion site is infiltrated. In Addison's crisis, the client's condition may be precarious, and any complications with IV therapy could worsen the situation. It is essential to report this finding promptly to prevent further complications.
Choice D rationale:
A serum glucose level of 85 mg/dL. While monitoring glucose levels is essential in many situations, a glucose level of 85 mg/dL is within the reference range, which means it is not the most critical finding in Addison's crisis.
Correct Answer is C
Explanation
"I realize that my life must go on, but sometimes I wonder why.”
Choice A rationale:
This statement may indicate frustration with physical limitations, which is common in older adults, especially after surgery. It does not necessarily indicate a need for bereavement counseling.
Choice B rationale:
Difficulty remembering simple things can be attributed to normal aging processes or other factors not directly related to bereavement.
Choice C rationale:
Expressing a sense of wondering "why”. after the loss of a spouse suggests ongoing grief and a potential need for bereavement counseling to process feelings and find meaning in life after the loss.
Choice D rationale:
Depending on children who live close-by is a common support mechanism for older adults and does not directly indicate a need for bereavement counseling.
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