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 A
Explanation
A. Diaper changes help assess the baby’s urinary output and general hydration status. If the newborn is producing urine, it suggests proper kidney function and adequate fluid intake, which are essential considerations before transferring the baby to the nursery.
B. While this promotes bonding and allows the mother to assess her baby visually, it does not directly address health indicators such as feeding or elimination, which are critical for ensuring the newborn’s well-being.
C. Noting if the baby is sleeping is a routine observation but does not address the importance of maternal bonding.
D. Whether the family has seen the baby is less critical than ensuring the mother has had early bonding opportunities.
Correct Answer is C
Explanation
A. Feeling for a carotid pulse is part of the assessment process but is not the first step in responding to an unresponsive client. Immediate action to summon emergency help is the priority.
B. Bringing a glucometer to the room is not appropriate at this stage. While checking blood glucose might be necessary, the first step is to get emergency assistance.
C. Obtaining emergency help is the most critical first step when encountering an unresponsive client. Emergency help ensures that appropriate interventions are initiated promptly.
D. Checking the blood pressure is part of a complete assessment but is not the most urgent action. The priority is to call for emergency assistance rather than performing further assessments.
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