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 C
Explanation
Choice A reason: A skilled nursing facility is not the best option for this client because it provides long-term care for clients who need 24-hour nursing supervision and assistance with activities of daily living, but not intensive rehabilitation.
Choice B reason: Home care services are not the best option for this client because they provide intermittent care for clients who are able to manage most of their needs at home, but not comprehensive rehabilitation.
Choice C reason: A rehabilitation facility is the best option for this client because it provides short-term care for clients who need intensive physical, occupational, and/or speech therapy to restore or improve their function and independencE.
Choice D reason: A sub-acute care facility is not the best option for this client because it provides intermediate care for clients who need less intensive medical and nursing care than in an acute hospital, but not specialized rehabilitation.
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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