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. Birth, 2 months, 12 months, and boosters every 7 to 10 years. - This schedule doesn't align with the typical whooping cough vaccination schedule.
B. 1, 6, 9 months, and boosters at 12 months of age and before entering school. - This schedule doesn't match the typical whooping cough vaccination schedule.
C. 1 year of age, 6 years of age, and with each exposure. - This schedule doesn't align with the standard vaccination recommendations for whooping cough.
D. 2, 4, 6 months, and boosters at 15 to 18 months and 4 to 6 years of age. - This schedule aligns with the recommended vaccination schedule for whooping cough by the CDC, providing primary vaccinations at 2, 4, and 6 months and booster doses later in childhood.
Correct Answer is C
Explanation
A. Checking for kinks in the drainage tubing is important, but the observed clots and thick red fluid suggest potential complications that require immediate attention and should be reported. B. Waiting for an hour to observe again could delay necessary interventions if there's an issue with bleeding or clot formation, so reporting immediately is more prudent.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation. Reporting to a superior nurse allows for prompt evaluation and intervention.
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