The practical nurse (PN) is administering a saline enema to a client who was admitted
because of a fever of unknown origin and is now constipated. Which techniques should
the PN use? (Select all that apply.)
Position client in left lateral recumbent position to expose buttocks.
Chill the enema solution to help reduce the client's fever.
Encourage client to retain solution for at least 5 minutes.
Insert lubricated tip of tubing 3 to 4 inches into the rectum.
Correct Answer : A,C,D
Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.
Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.
Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.
Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.
Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Sitting quietly in her mother's lap may be a sign of shyness or caution in a healthcare setting, but it is not necessarily a typical behavior for a 4-year-old child.
Choice B: Drawing a picture of oneself with facial features is a more advanced skill and may be seen in older preschool-aged children. It is not a typical behavior for a 4- year-old.
Choice C: Talking to an imaginary friend is a normal and developmentally appropriate behavior for a 4-year-old child. Imaginary friends can provide comfort and companionship during times of stress or change.
Choice D: Ignoring other children in the play area may be a sign of shyness or introverted behavior but is not necessarily indicative of normal behavior for a 4-year-old. Social interaction with peers can vary widely among children.
Correct Answer is A
Explanation
Choice A: Increased Ca+ influx with sympathetic stimulation that raises the heart rate is a manifestation of sympathetic innervation. Sympathetic activation leads to the release of norepinephrine, which enhances the influx of calcium ions (Ca+) into cardiac muscle cells, resulting in increased contractility and heart rate.
Choice B: Sympathetic activation does increase the inotropic effect (contractility) of the heart, but it is primarily mediated by the increased influx of calcium ions (Ca+).
Choice C: Sympathetic activation does not decrease dromotrophy (conduction speed). Instead, it can increase the conduction speed through the cardiac conduction system.
Choice D: Increased Na+ influx with sympathetic stimulation does not reduce pacemaker firing; instead, it contributes to the enhanced excitability and automaticity of cardiac cells.
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