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","D","E"]
Explanation
A. Oatmeal is a good choice for breakfast.
Oatmeal is a good source of iron and can be part of a vegetarian diet. It is a suitable option for increasing iron intake while adhering to vegetarian dietary restrictions.
B. Eat red meat just until the anemia is resolved.
This option is not suitable for a vegetarian client. Red meat is a source of heme iron, but it conflicts with the client’s dietary preferences and does not align with a vegetarian diet.
C. Take two prenatal vitamins with iron daily.
Doubling the dose of prenatal vitamins is not recommended without specific advice from a healthcare provider. The prescribed dosage should be followed, and dietary changes should be the focus.
D. Add lentils and black beans to soups.
Lentils and black beans are excellent sources of non-heme iron, which fits well within a vegetarian diet. Including these foods in meals can help boost iron levels effectively.
E. Increase green leafy vegetables in the diet.
Green leafy vegetables are high in non-heme iron and are suitable for vegetarians. Increasing their consumption supports iron intake and helps manage anemia.
Correct Answer is B
Explanation
A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.
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