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","D","F"]
Explanation
A. Avoid discussion of negative situations that may occur in the future.
Not Applicable
Avoiding discussions about potential negative situations is not helpful in addressing caregiver stress. Open and honest conversations about future challenges can prepare caregivers and help them develop coping strategies. Addressing potential issues proactively supports both the caregiver and the care recipient.
B. Involve your mother in the decision-making process.
Applicable
Involving the mother in decision-making helps to validate her feelings and preferences, which can alleviate some of the caregiver’s stress. Shared decision-making respects the mother’s autonomy and can reduce feelings of resentment or frustration from the daughter. This approach fosters a collaborative environment that can ease the caregiver’s burden.
C. Saying "no" to things involving the care of your mother is a selfish action.
Not Applicable
Saying "no" is not a selfish action but a necessary step for maintaining personal well-being. Encouraging caregivers to set boundaries is crucial for managing stress and preventing burnout. Supportive statements should affirm that self-care is essential for effective caregiving.
D. It is okay not to love or like your mother when you are caring for her.
Applicable
Acknowledging that it is okay not to have positive feelings towards the person being cared for can reduce caregiver guilt and stress. Caregivers may experience complex emotions, and recognizing these feelings as normal helps them manage their roles more effectively. This statement supports emotional honesty and resilience in caregiving.
E. Helping your mother should be easier than raising a child.
Not Applicable
Comparing caregiving to raising a child dismisses the unique challenges of elder care and can invalidate the caregiver’s stress. Each caregiving situation is different, and caregivers should be encouraged to recognize and address the specific difficulties they face. Comparisons can be unhelpful and diminish the caregiver’s experiences.
F. Take time for yourself and the other relationships that you care about.
Applicable
Encouraging caregivers to take time for themselves is essential for preventing burnout and maintaining overall well-being. Self-care helps caregivers manage stress and sustain their own health and relationships. This approach supports the caregiver’s needs and acknowledges the importance of balance.
G. You made a promise to your mother that you need to keep.
Not Applicable
Emphasizing promises can increase feelings of guilt or obligation rather than addressing the caregiver’s stress. Caregiver support should focus on practical strategies for managing stress rather than reinforcing burdensome promises. This statement can exacerbate feelings of pressure and strain
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}
Explanation
- Dark Room Lighting
Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment. - Malnutrition
Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment. - Pressure Injuries
Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.
Not Consistent with Elder Mistreatment
- Poor Hygiene
Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment. - Bilateral Leg Edema
Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment. - Short Term Memory Loss
Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.
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