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 D
Explanation
The correct answer and explanation is:
d) Ask when the nurse should return. Correct
This is the action that the PN should take when entering the client's room and finding the couple in bed together. Asking when the nurse should return respects the client's privacy, dignity, and autonomy, while also ensuring that the client receives the necessary care.
The PN should acknowledge that the client has the right to express her sexuality and intimacy, as long as it is consensual and safe . The PN should also avoid making any judgments or assumptions about the client's relationship or preferences.
a) Request that the man get up and leave.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Requesting that the man get up and leave is rude, disrespectful, and intrusive, as it violates the client's privacy, dignity, and autonomy. The PN should not interfere with the client's sexual or intimate activities, unless there is a clear indication of abuse, coercion, or harm.
b) Report the incident to the family.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Reporting the incident to the family is inappropriate and unethical, as it breaches the client's confidentiality and autonomy. The PN should not share any information about the client's sexual or intimate activities with anyone without her consent, unless there is a clear indication of abuse, coercion, or harm.
c) Exit the room and quietly close the door.
This is not the action that the PN should take when entering the client's room and finding the couple in bed together. Exiting the room and quietly closing the door is passive and neglectful, as it ignores the client's needs and care.
The PN should not avoid or delay providing care to the client because of her sexual or intimate activities, unless she requests so . The PN should also communicate with the client and her partner in a respectful and professional manner.
Correct Answer is A
Explanation
Choice A reason: "Move objects away from the client." This instruction should be included in the teaching because it can prevent injury and protect the client from harm during a seizurE.
Choice B reason: "Restrain the client." This instruction should not be included in the teaching because it can cause injury and increase agitation and anxiety for the client during a seizurE.
Choice C reason: "Place the client on his back." This instruction should not be included in the teaching because it can increase the risk of aspiration and airway obstruction for the client during a seizurE.
Choice D reason: "Insert a padded tongue blade into the client's moutH." This instruction should not be included in the teaching because it can cause injury and choking for the client during a seizurE.
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