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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assessing the client's mental status is crucial before administering zolpidem, a sleep aid, as it helps ensure the client is alert enough to take the medication safely. This assessment includes evaluating the client's level of consciousness, orientation, and cognitive function.
B. Monitoring body temperature might be necessary in certain clinical situations, but it's not directly relevant before administering zolpidem unless there are specific concerns related to body temperature.
C. Assessing bowel sounds is an important part of a comprehensive physical assessment, but it's not directly tied to the administration of a sleep aid like zolpidem.
D. Evaluating skin integrity is important for overall patient care, but it's not specifically linked to the assessment needed before administering a sleep medication like zolpidem.
Correct Answer is D
Explanation
A. Term 6, Premature 3, Abortion 3, Living 2. This choice is incorrect because it counts each miscarriage as both a term and a premature birth. A term birth is one that occurs after the completion of the 37th week of gestation. A premature birth is one that occurs before the completion of the 37th week of gestation. A miscarriage is a pregnancy loss that occurs before the completion of the 20th week of gestation.
B. Term 2, Premature 3, Abortion 3, Living 2. This choice is incorrect because it counts each miscarriage as a premature birth. A miscarriage is not a premature birth because it occurs before the viability of the fetus.
C. Term 2, Premature 1, Abortion 0, Living 3. This choice is incorrect because it does not count the miscarriages as abortions. An abortion is any pregnancy loss that occurs before the completion of the 20th week of gestation, regardless of whether it is spontaneous or induced.
D. Term 3, Premature 0, Abortion 3, Living 2. This choice is correct because it accurately reflects the client's obstetrical history. The client has had three term births (two living children and one current pregnancy), no premature births, three abortions (all miscarriages in the first trimester), and two living children.
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