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.)
Insert lubricated tip of tubing 3 to 4 inches into the rectum.
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.
Clamping the enema administration tubing
Correct Answer : A,B,D,E
A. Inserting the lubricated tip of the tubing 3 to 4 inches into the rectum allows for the proper administration of the enema.
B. Positioning the client in the left lateral recumbent position helps expose the rectum for the enema administration.
C. Chilling the enema solution isn't recommended as it might cause discomfort or shock to the client.
D. Encouraging the client to retain the solution for at least 5 minutes helps ensure effectiveness.
E. Clamping the enema administration tubing after filling the enema bag helps control the flow during the procedure.
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Related Questions
Correct Answer is D
Explanation
A. Allowing the client to go to the bathroom independently may pose a safety risk, particularly if the labor progresses rapidly or if she experiences increased discomfort.
B. Assisting the client to the bathroom might not be advisable if she is in active labor, as her condition can change quickly, and she may need immediate access to care.
C. Offering the client a bedpan or urinal would allow for bladder emptying but may not address the urgency of her desire to ambulate.
D. Encouraging the client to hold off until she is further dilated is appropriate, as a full bladder can impede labor progression and lead to complications. This allows for monitoring and assessment of her condition, ensuring that she remains safe and that labor can continue effectively.
Correct Answer is A
Explanation
A. Call the healthcare provider and clarify the prescription. - If the PN suspects an error in a prescription, especially regarding a child's dosage, it's imperative to communicate concerns to the healthcare provider for clarification and potential adjustment.
B. Request verification of the prescription by the charge nurse. - While involving another nurse might provide a second opinion, it's crucial to involve the prescriber to rectify any potential prescription errors.
C. Tell the pharmacy to send an accurate child's dosage. - The prescription should be confirmed with the healthcare provider before any medication is dispensed or administered.
D. Ask another nurse if adult dosages are ever given to children. - While seeking information from peers is valuable, this situation calls for direct clarification from the prescriber to ensure proper dosing for the child.
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