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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Encouraging community members to practice fire drills is an activity that is a part of the prevention/mitigation phase of the disaster management cycle because it can reduce the risk of injury or death from fire by increasing the awareness and preparedness of the community.
Choice B reason: Identifying community members who have disabilities is an activity that is a part of the prevention/mitigation phase of the disaster management cycle because it can reduce the vulnerability of these individuals by ensuring that they have access to appropriate resources and assistance in case of a disaster.
Choice C reason: Providing first aid to community members affected by a tornado is not an activity that is a part of the prevention/mitigation phase of the disaster management cycle, but rather the response phase, which involves delivering immediate and short-term assistance to save lives and meet basic needs during and after a disaster.
Choice D reason: Assisting community members in developing a disaster plan is not an activity that is a part of the prevention/mitigation phase of the disaster management cycle, but rather the preparedness phase, which involves enhancing the readiness and capabilities of individuals, organizations, and communities to respond to and recover from a disaster.
Correct Answer is B
Explanation
Choice A reason: Performing carotid massage is not an appropriate action for the nurse to take because it can worsen the client's condition by decreasing the blood flow to the brain, causing further ischemia or hemorrhagE. Carotid massage is a technique that involves applying pressure to the carotid artery to slow down the heart rate, which can be dangerous for clients who have a strokE.
Choice B reason: Calling for help is an appropriate action for the nurse to take because it can initiate the rapid response team and activate the stroke protocol, which can improve the client's outcome and survival. The nurse should also assess the client's vital signs, neurological status, and time of symptom onset, and report them to the health care provider.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for the nurse to take because it can increase the risk of aspiration and pneumonia, which can complicate the client's recovery and prognosis. The nurse should avoid giving anything by mouth to the client until their swallowing ability is evaluated by a speech therapist or a swallow study.
Choice D reason: Administering thrombolytics is not an appropriate action for the nurse to take because it requires a physician's order and confirmation of the type and cause of stroke by a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. Thrombolytics are drugs that dissolve blood clots and restore blood flow, which can be beneficial for clients who have ischemic stroke, but harmful for clients who have hemorrhagic strokE.
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