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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.

Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.

Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.

Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.

A. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. B. Schedule time later in the morning to review the use of the incentive spirometer with the client. C. Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.

Correct Answer is C

Explanation

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Correct Answer is D

Explanation

The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Correct Answer is C

Explanation

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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.)