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: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.
Choice B: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.
Choice C: Skim milk, grapes, and lettuce are good sources of water that can help dilute the sodium level in the blood. Bacon is a high-sodium food, but it is a small portion compared to the other choices and can be balanced by the rest of the meal.
Choice D: this combination contains higher sodium levels, especially canned soup, so it's not the ideal choice.
Correct Answer is A
Explanation
Choice A: A practical nurse assisting the healthcare provider with a lumbar puncture at the bedside is a high-risk procedure that requires direct supervision by an RN or a qualified healthcare provider. The RN should ensure the procedure is performed safely and effectively, as it involves potential risks and complications.
Choice B: Starting a transfusion of packed red blood cells is an important nursing intervention, but it does not necessarily require direct supervision by an RN, especially if the nurse has been trained and is competent in administering blood transfusions.
Choice C: Weighing an obese bedfast client using a bed scale is a routine nursing task that can be performed by unlicensed assistive personnel (UAP) with appropriate training. While the RN should ensure that the UAP is properly trained, direct supervision may not be required for this specific task.
Choice D: Accessing a client's implanted port to start an infusion of Ringer's Lactate is a nursing task that can be performed by a graduate nurse, especially if they have received appropriate training and competency validation. Direct supervision by an RN may not be necessary in this situation.
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