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An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

The solution temperature should be determined by the client’s comfort level

The temperature of the enema is unrelated to the enema’s eﬀectiveness

The solution should approximate the client’s body temperature (98°F or 36°C).

The temperature should be higher (110°F or 43°C) than the client’s body temperature

Answer and Explanation

The Correct Answer is C

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
The temperature of the enema solution aﬀects the eﬀectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.

Option A is incorrect because the client’s comfort level may not reﬂect the optimal temperature for the

enema.

Option B is incorrect because the temperature of the enema does aﬀect its eﬀectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.

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Correct Answer is C

Explanation

Choice A reason: Completing a survey of the various ethnicities represented in the nurse's community is a good way to learn about the diversity of the population, but it is not the first step in developing cultural competencE. The nurse should first examine their own cultural background and biases before learning about others.

Choice B reason: Studying the beliefs and traditions of persons living in other cultures is a valuable way to gain knowledge and understanding of different worldviews, but it is not the first step in developing cultural competencE. The nurse should first be aware of their own cultural values and assumptions before exploring those of others.

Choice C reason: Considering how the nurse's own personal beliefs and decisions are reflective of their culture is the first step in developing cultural competencE. The nurse should recognize that their culture influences their perception, communication, and behavior, and that they may have prejudices or stereotypes that affect their interactions with clients from different cultures.

Choice D reason: Inviting a family from another culture to join the nurse for an event is a nice gesture to show respect and interest in other cultures, but it is not the first step in developing cultural competencE. The nurse should first develop self-awareness and sensitivity to their own cultural identity before engaging with others.

A. Asking how they are managing at home B. Going automatically into the client's bedroom C. Arranging mutual future visits D. Thanking the client for arranging a home visit E. Sitting down and discussing with the client and family members

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Asking how they are managing at home is an appropriate action by the nurse because it shows interest and respect for the client's situation, needs, and preferences.

Choice B reason: Going automatically into the client's bedroom is not an appropriate action by the nurse because it violates the client's privacy and autonomy. The nurse should ask for permission before entering any room in the client's homE.

Choice C reason: Arranging mutual future visits is an appropriate action by the nurse because it demonstrates collaboration and continuity of care with the client.

Choice D reason: Thanking the client for arranging a home visit is not an appropriate action by the nurse because it implies that the nurse is doing a favor for the client, rather than providing professional servicE.

Choice E reason: Sitting down and discussing with the client and family members is an appropriate action by the nurse because it facilitates communication, rapport, and education with the client and their support system.

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An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature?

Nursing Test Bank

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