A nurse needs to administer an oil retention enema to a client. ...

[Mr3Hunna]

A nurse needs to administer an oil retention enema to a client. Which of the following interventions should the nurse perform if disposable equipment is unavailable?
 
  A) Insert a 14F to 22F tube into the rectum.
  B) Insert 100 to 200 ml of warm oil into the rectum with syringe.
  C) Insert a suppository into the rectum.
  D) Insert a small funnel and instill solution in the rectum.

Question 2

A nurse is conducting a mental status assessment for a client admitted to a health care facility. Under which conditions would the nurse need to collect the greatest proportion of objective assessment data?
 
  A) When the client has visible wounds
  B) When the client pays attention to the nurse's instruction
  C) When the client has taken an overdose of drugs
  D) When the client has an active infection

[wergv]

Answer to Question 1

A
Feedback:
If disposable equipment is not available during an oil retention enema, the nurse should lubricate and insert a 14F to 22F tube into the rectum. A small funnel is not inserted into the rectum but is attached to the tube. The nurse instills approximately 100 to 200 ml of warmed oil slowly only after the tube is inserted in the rectum, not before that. Inserting a suppository or syringe in the rectum is not done in an oil retention enema.

Answer to Question 2

C
Feedback:
The nurse would need to collect more objective assessment data if the client had taken an overdose of drugs. However, objective assessment data would not be required if the client has wounds, can pay attention to the nurse's instruction or has an infection; none of these conditions compromises the client's ability to provide useful subjective data.

[Mr3Hunna]

Thank you!

[wergv]

Always glad to help...