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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 A

Explanation

Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve this client's nutritional status because it can enhance the client's muscle strength and coordination for chewing and swallowing, which are often impaired by myasthenia gravis.

Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve this client's nutritional status because it can increase the risk of dehydration and constipation, which can worsen the client's condition and appetitE.

Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve this client's nutritional status because it can lead to weight gain, hyperglycemia, and cardiovascular problems, which can complicate the management of myasthenia gravis.

Choice D reason: Eating three large meals per day is not a good suggestion to improve this client's nutritional status because it can cause fatigue, bloating, and aspiration, which can affect the client's ability and willingness to eat. The client should eat small, frequent meals that are easy to chew and swallow.

A. Hypertension B. Tinnitus C. Hypotension D. Tachycardia

Correct Answer is A

Explanation

Choice A reason: Hypertension is a manifestation of increased intracranial pressure because it is part of the Cushing's triad, which is a set of signs that indicate increased intracranial pressure and impaired cerebral perfusion. The other signs of Cushing's triad are bradycardia and irregular respirations.

Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure because it is a symptom of hearing loss, ear infection, or ear damage, not increased intracranial pressurE. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors such as exposure to loud noise, aging, or medication side effects.

Choice C reason: Hypotension is not a manifestation of increased intracranial pressure because it is a sign of decreased blood pressure, not increased intracranial pressurE. Hypotension can be caused by various factors such as dehydration, blood loss, or shock.

Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure because it is a sign of increased heart rate, not increased intracranial pressurE. Tachycardia can be caused by various factors such as anxiety, fever, or pain.

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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?

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