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 B
Explanation
Choice A: Broccoli is not typically restricted before a gallbladder ultrasound.
Choice B: Instructing the client to avoid consuming a milkshake the night before the test is important because a fatty meal can affect gallbladder contraction and visualization during the ultrasound.
Choice C: A garden salad is not typically restricted before a gallbladder ultrasound.
Choice D: Coffee is not typically restricted before a gallbladder ultrasound.
Correct Answer is A
Explanation
Choice A: Keeping a record of food and drinks consumed daily, often referred to as food journaling or keeping a food diary, is a recommended initial approach to a weight loss plan. It helps clients become aware of their eating habits and can assist in identifying areas where dietary changes may be needed.
Choice B: Participating in a group exercise class 3 times a week is a beneficial component of a weight loss plan, but it is not specifically related to the initial approach to weight loss.
Choice C: Engaging in strenuous activity for an hour daily can be part of a weight loss plan, but it may not be the initial approach for everyone, especially if the client is not currently physically active. The initial approach often involves dietary changes and gradually increasing physical activity.
Choice D: Planning low carbohydrate and high protein meals can be a dietary strategy for weight loss, but it may not be the initial approach for all clients. Dietary recommendations should be individualized based on the client's preferences and needs.
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