Author Question: While the nurse is administering an enema with a standard enema bag, which intervention is important ... (Read 128 times)

vinney12 · **on:** Jun 25, 2018

While the nurse is administering an enema with a standard enema bag, which intervention is important to implement?

a. Keeping the solution at room temperature
b. Positioning the patient on the right side
c. Raising the enema bag to 12 inches above the patient
d. Instructing the patient to release the enema solution as soon as possible

Question 2

What primary intervention should a nurse who is preparing a blood transfusion perform?

a. Set up the Y tubing.
b. Obtain 0.9 saline.
c. Verify the blood product and the patient.
d. Have the patient void or empty the urine drainage container.

kaillie · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

A
Maintaining a the correct temperature for the solution is a critical safety precaution. If the solution is too hot it will burn the intestinal mucosa. Cold water can cause abdominal cramping. Solution dripped on inner wrist should be comfortable. Unless patient condition requires a different position, the patient will lay on his/her left side with the top leg flexed (left lateral Sims') and the bag of solution will be hung 18 inches above the rectum. The patient will be instructed to retain the solution as long as possible for maximum therapeutic effect.

Answer to Question 2

C
Correctly verify the product and identify the patient with a person considered qualified by your agency. Strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Clerical errors are the cause of most hemolytic transfusion reactions. Y tubing is used to facilitate maintenance of IV access in case a patient will need more than 1 unit of blood. However, the focus here is on prevention of possible blood reactions. Use of Y tubing will not prevent a blood reaction. Normal saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of donor blood. However, strict adherence to verification procedures before administration of blood or blood components reduces the risk of administering the wrong blood to the patient. Empty the urine drainage collection container or have the patient void. If a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory.