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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 ["B","C","D"]

Explanation

Choice A reason: Nurses performing duties outside of the nurses' typical job description is not a component of a disaster plan. Nurses should only perform tasks that are within their scope of practice, license, and competencE.

Choice B reason: A plan for comprehensive practice drills is a component of a disaster plan. Nurses should be involved in conducting regular drills to test and improve the preparedness and response of the staff and facility.

Choice C reason: Identification of resources to meet anticipated needs for food, water, and supplies is a component of a disaster plan. Nurses should be involved in assessing and securing the necessary resources to provide adequate care and support for the clients and staff during a disaster.

Choice D reason: An internal and external communication plan is a component of a disaster plan. Nurses should be involved in establishing and maintaining effective communication channels with other health care providers, agencies, authorities, media, and community during a disaster.

Choice E reason: Discharge all surgical clients who are one day or more post-op is not a component of a disaster plan. Nurses should not discharge clients without proper assessment, documentation, education, and follow-up arrangements.

A. Decrease bright lights. B. Initiate IV access. C. Administer antibiotics. D. Implement droplet precautions.

Correct Answer is D

Explanation

Choice A reason: Decreasing bright lights is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Decreasing bright lights can help reduce photophobia and headache, but it is not an urgent intervention.

Choice B reason: Initiating IV access is not the first action that the nurse should perform because it does not address the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Initiating IV access can facilitate fluid and medication administration, but it is not an immediate intervention.

Choice C reason: Administering antibiotics is not the first action that the nurse should perform because it requires a physician's order and confirmation of the diagnosis and causative organism by laboratory tests such as blood culture or cerebrospinal fluid (CSF) analysis. Administering antibiotics can treat bacterial meningitis, but it is not a priority intervention.

Choice D reason: Implementing droplet precautions is the first action that the nurse should perform because it addresses the priority problem of potential infection and inflammation of the meninges, which can cause serious complications such as brain damage or deatH. Implementing droplet precautions can prevent transmission of meningitis to other clients or staff, as meningitis can be spread by respiratory droplets from coughing, sneezing, or talkinG.

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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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Naxlex Comprehensive Predictor Exams

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