When administering a saline enema, the practical nurse (PN) inserts the enema tubing three inches into the client's rectum, and elevates the container six inches above the client's body. When the clamp is opened, the solution does not infuse. Which action should the PN take?
Re-lubricate the tubing and re-insert it.
Insert the tubing an additional three inches into the rectum.
Raise the saline container six inches higher.
Instruct the client to take several slow, deep breaths.
The Correct Answer is B
A. Re-lubricating the tubing and re-inserting it is unnecessary if the enema solution is not infusing; the primary issue is likely related to the tubing's position or the height of the container.
B. Inserting the tubing an additional three inches into the rectum ensures that it is positioned correctly for the solution to flow. If the tubing is not inserted far enough, the solution may not enter the rectum.
C. Raising the saline container higher is not needed since it is already six inches above the client’s body. The problem is more likely related to the tubing’s depth rather than the height of the container.
D. Instructing the client to take deep breaths does not affect the infusion of the enema solution. The solution's flow is influenced by the mechanics of the enema administration, not by the client’s breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Exhaling slowly after two seconds is not part of the incentive spirometer use. Proper technique involves a slow, steady inhalation, not exhalation.
B. Blowing forcefully into the mouthpiece indicates incorrect use of the spirometer. The client should inhale slowly and deeply through the mouthpiece to expand the lungs and improve ventilation.
C. Using a tight seal around the mouthpiece is correct and necessary to ensure that the spirometer measures the volume of air accurately.
D. Sitting upright during the treatment is correct as it maximizes lung expansion and facilitates deep breathing.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Leaving an Older Adult in a Public Space
- Abandonment: Leaving the client alone in a public space can be considered abandonment, as it involves a failure to provide necessary care and supervision.
- Untreated Pressure Injuries
- Neglect: Untreated pressure injuries indicate a failure to provide adequate care and preventative measures, which is a form of neglect.
- Oversedation
- Physical Abuse: Administering excessive medication or sedation without proper medical justification can be a form of physical abuse.
- Poor Personal Hygiene
- Neglect: Poor personal hygiene often results from neglect, where the caregiver fails to assist with or encourage personal care practices.
- Depression or Withdrawn Behavior
- Neglect: Depression or withdrawn behavior can result from neglectful conditions, such as a lack of social interaction or emotional support.
- Bruises in Various Stages of Healing
- Physical Abuse: Bruises in various stages of healing are a classic sign of physical abuse, indicating that the client has been subjected to physical harm.
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