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. Placing a biohazard bag over the basin and sealing it is not appropriate because the specimen should have been collected directly into a sterile container, and the specimen's current state in a non-sterile basin is not acceptable for lab analysis.
B. Assisting the client in obtaining another specimen is necessary to avoid cross contamination.
C. Using a wooden applicator to place the sputum specimen in a sterile container is the incorrect as it breaches sterility.
D. Applying gloves and placing the tissue and specimen in a container is incorrect as the specimen must be in a sterile container from the start. Using a non-sterile basin means the specimen might be contaminated.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Response 1
A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.
B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.
C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.
D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.
Response 2
A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.
B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.
C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.
D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.
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