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 B
Explanation
A. Gravida (G) refers to the total number of pregnancies. This option counts all four pregnancies (twins, son, fetal loss) which is correct. Parity (P) refers to the number of pregnancies that have reached viable gestational age (20 weeks or beyond). Since the fetal loss at 24 weeks is included in the count, the parity is incorrectly stated as 4.
B. Gravida (G) counts all four pregnancies, which is accurate. Parity (P) considers only the pregnancies that reached viable gestational age. As there are two children from the twins, one child aged 4 years, and the fetal loss at 24 weeks (which is not considered as viable gestational age), the correct parity is 3.
C. Gravida (G) represented as 'S' typically indicates "stillbirths" rather than the total number of pregnancies. It does not provide an accurate representation of all pregnancies, so this is not the correct choice.
D. Gravida (G) counts five pregnancies, which doesn't accurately represent the scenario as there have been four pregnancies, not five. Parity (P) as 2 doesn't account for the twins, so it's incorrect.
Correct Answer is B
Explanation
A. Sodium level of 130 mEq/L is slightly below the lower limit of the reference range but might not have as immediate an impact on safety as a critically low hemoglobin level.
B. Hemoglobin of 8.9 grams/dL is significantly below the normal range and indicates a substantial drop in red blood cells, which can lead to impaired oxygen transport and potentially severe postoperative complications like inadequate tissue perfusion and oxygenation.
C. Potassium level of 3.4 mEq/L is slightly below the lower limit of the reference range but might not pose an immediate threat compared to a critically low hemoglobin level.
D. Blood urea nitrogen (BUN) of 20 mg/dL is at the upper limit of the reference range but might not have an immediate implication for client safety compared to a critically low hemoglobin level.
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