fundamentals exam 3

Leaves the bed in the lowest position throughout the procedure

A nurse is observing an assistive personnel (AP) who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene?

Lift the penis perpendicular to the body. Lifting the penis to a position perpendicular to the body, or at a 90° angle, while applying light traction straightens the urethral canal to facilitate catheter insertion.

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take?

At least 30 min The enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min.

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations?

reposition client over the bedpan in the dorsal recumbant position. for infants or young children, hold the buttocks together to assist in retention of the enema

what should I do if client cannot retain enema solution

Return-flow Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas?

"Hold the crutches on your unaffected side when preparing to sit in a chair."

A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?

Lower the container to allow the solution to flow back out. Return-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times.

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take?

7.5 cm to 10 cm (3 to 4 in) This is the appropriate length of insertion for an adult client.

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube?

Leave a space between the penis and sheath portion tip. The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine.

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take?

Offer to assist the client with nonpharmacological relief strategies. The oxycodone would not have had time to peak and to be effective after 15 min. The nurse should offer to assist the client with nonpharmacological pain relief strategies until the medication has had time to work. Oral oxycodone peak effects should be noted 60 to 90 min after administration.

A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take?

Flexing the shoulder by raising the arm from a side position to a 180° angle

A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?

The client is diaphoretic. The nurse should identify that sweating is an objective manifestation of pain. Objective data is information the nurse can gather by using their five senses. Sweating can be visually noticed by the nurse.

A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain?

Negligence Negligence means failure to perform in a manner that a reasonable person would have. By failing to assess the client's pain and administer the client's pain medication, the nurse was negligent.

A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to assess the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with?

Face is correct. Face is one of the categories included in the FLACC pain assessment. The nurse should observe the client's facial expression and determine a score. Legs is correct. Legs is one of the categories included in the FLACC pain assessment. The nurse should observe the client's position, tone, and extremities and determine a score. Consolability is correct. Consolability is a category included in the FLACC pain assessment. The nurse should observe the client to determine if they are consolable and assign a score.

A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.)

A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief. This is an example of autonomy. The nurse is providing the client their right of self-determination by permitting the client an ability to make an informed decision.

A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy?

Bear down The nurse should instruct the client to bear down as if to void because this relaxes the external sphincter and aids in the insertion procedure.

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure?

Deflate the balloon completely before removal. Removing an indwelling urinary catheter while inflation solution remains in the balloon is likely to cause trauma to the urethral canal. Therefore, the nurse should deflate the balloon completely prior to removing an indwelling urinary catheter.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take?

"Your family member has the right to receive effective pain management." According to the American Society for Pain Management Nursing and the Hospice and Palliative Nurses Association position statement, end-of-life effective pain management is a basic human right. Clients who are receiving end-of-life care should receive special consideration for pain management.

A nurse is providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family?

Anus The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from the area that is least contaminated to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should therefore be cleansed last.

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last?

Move their leg behind their body.

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

nociceptive pain

felt in a tissue organ or damaged part of the body or referred pain somatic, visceral, and cutaneous

indwelling have an increased incidence of UTI because of prolonged time they are in place. All catheters should be discontinued as soon as possible.

is there a difference in the incidence of UTI among different types of catheters

female are at a higher risk because of a shorter uretha that increases risk of infection because the distance for bacteria to travel into the bladder is shorter. also fecal matter. advanced age and prolonged indwelling catheter use increase the risk of uti

is there a difference in uti in male and female clients

chronic pain

sudden or slow onset of any intensity and is constant or recurring without an anticipated or predictable end. duration longer than 6 months Ex: arthritis, back pain, and headaches

rigid distended abdomen, abdominal pain and cramping and bleeding. if abdomen becomes distended stop instillation. If abdomen becomes rigid stop instillation. If the client reports cramping slow the rate, if bleeding occurs stop the instillation, measure vitals, and notify provider

what can go wrong with enema administration? what should I do if complications occur

Stress is correct. Stress levels are psychological factors that can affect a client's experience with pain. Other psychological factors include mood/affect, catastrophizing (assuming the worst), and coping. Culture is correct. A client's identified culture is a social factor that can affect a client's experience with pain. Social factors also include economic factors, the social environment, and social support. Social support is correct. The availability of support from family and or friends is a social factor that can affect a client's experience of pain. Social factors also include cultural and economic factors and the social environment. Disease severity is correct. The severity of a client's disease is a biological factor that can affect a client's experience of pain. Biological factors also include nociception, inflammation, and brain function.

A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.)

Grimacing is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes. Restlessness is correct. Clients who have cognitive impairment or communication challenges (e.g., expressive aphasia) require careful nursing assessment. The client might not report pain effectively, and the nurse should look for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes. Increased diaphoresis is correct. Objective indicators of pain include crying, sweating, restlessness, grimacing, or guarding by the client. Objective indicators are manifestations that can be observed by the nurse using their senses of sight, hearing, smell, and touch.

A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply.)

Check the catheter for kinks. The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed.

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first?

Administer 1 mg IM. When a client has a prescription that includes a range, and the client has never taken the medication previously, the nurse should administer the lowest dose to the client. If the dose is ineffective, the nurse can increase the dosage up to the maximum amount in the range prescribed by the provider.

A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take?

Measure the client's calf circumference and leg length from heel to knee. To ensure proper fit, the nurse should measure the widest part of the client's calf as well as the length of the client's leg from the heel to the knee. Antiembolic stockings that are too large will not apply the pressure needed to prevent deep-vein thrombosis. Antiembolic stockings that are too small could impair circulation in the client's legs.

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?

Naloxone is a reversal agent for respiratory depression caused by opioids. It works quickly to reverse the effects of opioids on the client's respiratory system.

A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression?

Chronic pain Chronic pain is pain that has been present usually for 3 to 6 months or longer after the injury or damage has healed. Examples of chronic pain are arthritis pain or pain from a back injury. Chronic pain can physically and emotionally debilitate a client.

A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain?

A 3-year-old toddler who has a fractured femur is correct. The FLACC Pain Scale is recommended for children from 2 months to 7 years. A 3 year old might not be able to accurately report their pain using a NRS or VAS due to their cognitive development at this age. A 14-year-old client who has severe cognitive and developmental delays is correct. Even though this client is of an age greater that than the ages recommended for use of the FLACC, this client has cognitive and developmental delays and might not be able to appropriately rate their pain using a NRS or VAS. The FLACC Pain Scale is recommended for children who are cognitively disabled. A 5-year-old preschooler who is experiencing pain during a sickle cell crisis is correct. A 5-year-old child might not be able to accurately report their level of pain using other pain scales. The FLACC Pain Scale is recommended for children from 2 months to 7 years.

A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.)

A client who is in the ICU for a gastrointestinal bleed. The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization?

evaluate the client for pain by observing their behavior. Clients who have cognitive impairment might be unable to appropriately report their pain. The nurse should observe for behaviors that suggest pain is present such as guarding, grimacing, restlessness, and other behavioral changes.

A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take?

Transcutaneous electronic stimulating unit (TENS unit) is correct. The nurse should include transcutaneous electronic stimulating unit (TENS unit) as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain. Massage is correct. The nurse should include massage as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain. Acupuncture is correct. The nurse should include acupuncture as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain. Cold therapy is correct. The nurse should include the application of cold therapy as a method of cutaneous stimulation. This nonpharmacological cutaneous stimulation can be effective for the relief of back pain.

A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.)

Fear of addiction is correct. Barriers to end-of-life pain management from a client or their family include fear of addiction. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life. Belief that pain is an expected part of their illness is correct. Barriers to end-of-life pain management from a client or their family include the belief that pain is an expected part of their illness. This leads to pain being undertreated or not treated at all. Every client has the right to effective pain management as they near the end of life. Inadequate pain assessment is correct. The client's pain assessment can be inadequate due to several factors, such as the client's denial of pain, the client being unable to verbally express their level of pain due to unconsciousness or aphasia, or the client's or nurse's fear of causing adverse effects from the prescribed medications.

A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.)

Backache is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain. Muscular pain is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain. Menstrual discomfort is correct. The nurse should discuss the fact that heat therapy, in the form of a heating pad or hot water bottle, is typically used for muscular pain relief, such as back pain or menstrual pain.

A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.)

"You can be taught how to use TENS therapy at home" is correct. TENS therapy can be provided by the nurse or the client can be taught to use the TENS unit and self-administer in the home setting. "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy" is correct. The intensity, pulse rate, and duration of each pulse of treatment with TENS therapy can be adjusted by the nurse or the client. The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas" is correct. These low-voltage electrical impulses reduce the nervous system's ability to transmit pain from the area of application to the brain. In addition, these impulses stimulate the body to produce endorphins, which also assist in relieving pain.

A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.)

A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury Neuropathic pain is often referred to as nerve pain and arises from the somatosensory system. Neuropathic pain includes diabetic neuropathy, phantom limb pain, and pain associated with a spinal cord injury. Neuropathic pain is frequently described as intense, shooting, or burning.

A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain?

Respiratory rate is correct. The nurse should plan to monitor the respiratory rate frequently. A finding below the expected reference range could indicate OIVI. Capnography is correct. The nurse should recognize that capnography (measuring carbon dioxide) can assist with identifying OIVI. Oxygen saturation is correct. The nurse should plan to monitor the client's oxygen saturation frequently or continuously, depending on policy. A finding below the expected reference range could indicate OIVI.

A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.)

Wipe the port with an alcohol swab or agency specified antiseptic is the first step. The nurse should wipe the port with an alcohol swab to decrease the amount of bacteria present.Attach a syringe to the collection port of the indwelling catheter is the second step. Attaching a syringe after disinfecting the port allows for withdrawal of the urine specimen.Withdraw 3 to 30 mL of urine is the third step. The amount of urine withdrawn will depend on the laboratory test prescribed. Transfer the urine to a sterile specimen container is the fourth step. While transferring the urine specimen to the sterile specimen container, the nurse should be careful not to touch the syringe to the outside of the container. This might result in contamination of the specimen, which could cause an incorrect diagnosis. Transport the specimen to the laboratory is the fifth step. Transporting the specimen to the laboratory is the last step in the process. The specimen should not be allowed to sit at room temperature. If the specimen cannot be immediately transported to the lab, the nurse should store the specimen according to laboratory policy.

A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Identify the correct sequence of steps that the nurse should take. (Move the steps of the process into the box on the right, placing them in the selected order of performance. All steps must be used.)

Left lateral with the right leg flexed This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.

A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions?

Place the client in the dorsal recumbent position on a bedpan. A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled.

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take?

Warm the enema solution prior to instillation. It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa.

A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take?

"You should write down the pain interventions you use and your pain rating before and after." Keeping a pain diary or a pain log can be helpful for the client to determine if medications or treatments are helping over time.

A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include?

"I will keep the morphine bottle in a locked cabinet in my kitchen." Morphine is a medication that carries significant risks to others, including children, and should only be accessible and used by the client for whom it is prescribed. Storing the medication in a high cabinet prevents accidental access to the morphine by others.

A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions?

A client who had surgery 3 hr ago and is receiving IV hydromorphone PRNMY Use of an opioid medication can decrease the respiratory rate, and the first 4 hr postoperative are when the client is at highest risk for surgical complications. Therefore, the nurse should identify that the client who had surgery 3 hr ago and is receiving IV hydromorphone is at greatest risk for respiratory depression.

A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression?

Consider each client's cultural preferences is correct. The nurse must consider client factors that can affect their perception, response to, and report of pain, such as culture and socioeconomic status. Determine the effectiveness of nonpharmacological strategies is correct. The nurse should evaluate the effectiveness of each individual pain strategy, including both pharmacological and nonpharmacological. This helps determine which strategies are ineffective so that more effective strategies can be used consistently .Use a pain scale specific to each client's cognitive abilities is correct. The nurse should ensure that the pain scale used to measure a client's pain level is appropriate to their abilities, whether performing an initial pain assessment or evaluating pain effectiveness.

A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.)

"Justice allows the client the opportunity to be treated fairly." Justice requires that all clients be treated fairly in regard to their pain management regardless of age, ethnicity, or history, such as substance use disorder or limited social and economic resources. Pain relief should be available to all clients.

A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make?

neuropathic pain

nerve pain no tissue damage diabetic neuropahty, phantom limb, pain with spinal cord. intense, shooting, or burning maybe numbness or pins and needles or even intense itching

Wong baker faces, FLACC scale, or CRIES scale

pain scales appropriate for children

the most common causes of hematuria are mechanical injury of the urethra, urinary calculi (stones), genitourinary cancer, UTI, Pyelonephritis (infection of kidney), and glomerulonephritis (infection of the glomerulus structure in the kidney)

what causes hematuria (blood in the urine)

Autonomic dysreflexia is a syndrome affecting clients with spinal cord injuries above the thoracic level. A stimulus from the autonomic nervous system causes hypertension, bradycardia, severe headaches, pallor below the level of injury and flushing above the level of injury, convulsions stroke and death. the most common causes are constipation and full bladders, which can be caused by clamping urinary catheters. The primary treatment for this condition is removal of the stimulus (or unclamping a catheter) Some medications are also prescribed to stabilized clients who have severe cases of autonomic dysreflexia.

what is autonomic dysreflexia and what should I do if I suspect that a client has this condition

elimination status by checking clients normal elimination pattern, last bowel movement, pain, ability to ambulate, structural abnormalities, and spincter control. nurse should complete an abdominal assessment

what should I assess before I give a client an enema

purpose and the procedure. positioning requirements and how long to retain the solution. let them know they may feel some discomfort

what should i teach a client before giving an enema

Always use sterile technique when placing a Foley catheter. Give appropriate and thorough perineal care (hygiene of the gentital region) assess equipment carefully to ensure a closed system and intervene to prevent prolonged catheter use

what strategies should I use to help keep clients from developing catheter associated UTIs

"A client's religious beliefs might affect the way they respond to pain" . The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as differences in ethnic backgrounds or religious beliefs. "The client's past pain experiences are not related to their current pain and pain management" The client's past pain experiences are not related to their current pain and pain management ."Pain control might be harder to achieve if the nurse and client speak different primary languages" The nurse should be aware of factors that could inhibit communication with the client and prevent pain control, such as language barriers or educational differences.

A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.)

Extend one leg and allow the client to slide down the leg to the floor.

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take?

20 min The nurse should apply heat therapy for no more 20 min at a time with at least a 20-min break after usage.

A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long?

"Can you point to where you are having your pain?" The nurse should use the PQRST mnemonic to obtain more information about the client's pain. This question evaluates the region of the client's pain.

A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"?

Aligning the nurse's knees with the client's knees just before the transfer

A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions by the nurse demonstrates correct transfer technique?

it is important to warm the enema solution to prevent cramping. test temp on arm prior. hypertonic and oil retention should be administered at room temp

does the enema have to be a certain temperature

yes

does urinary catheterization always require a providers order?

precipitating cause quality region severity timing

PQRST for pain

Lower the enema fluid container Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

presence of associated manifestations

a nurse in a clinic is collecting data about pain from a client who reports severe abdominal pain. nurse asks if there has been any nausea or vomiting, which characteristic is the nurse attempting to determine?

they can after the clients vital signs are stable and they are comfortable and do not require an alternative position. make sure AP is educated on procedure signs and symptoms and positioning. MEDICATED enemas should be administered by a nurse

can a RN/LPN delegate the enema administration

adult and adolescent- carefully insert 7.5-10cm (3-4in) child 5 cm-7.5 cm (2-3 in) for an infant 2.5 -3.75 cm (1-1.5)

how far should I insert the enema tip

hold or hang container no higher than 45 cm (18 in) above the level of the anus

how high should I raise the enema bag when administering a large volume cleansing enema

for cleansing enema ask client to retain solution 5-15 for a retention enema at least 30 minutes is the minimum

how long does a client have to retain the enema solution

left side lying sims position with the right knee flexed for adequte exposure of anus. for infant of small child use the dorsal recumbant position

how should I position a client for an enema

acute pain

sudden or slow onset of any intensity and an anticipated or predictable end. pain that lasts less than 6 months ex pain from tissue damage caused by trauma or injury

cancer pain

tumor pain, bone pain, chronic postsurgical pain, radiation induced pain and neuropathies related to chemotherapy

offer the client a pain scale

what action should the nurse take to determine the intensity of the pain

increased intracranial pressure glaucoma rectal or prostate surgery

what are contraindications for enemas

An elevated white blood cell count, urine with a pungent odor, increased sediment in the urine, confusion or alteration in mental status a change in urination pattern and fever can all indicate uti

what are the common manifestations of uti?

common indications include an inability to void because of retention the need for close hemodynamic monitoring and postsurgical recovery. standards of practice encourage the removal of a catheterization as soon as possible

what are the indications for urinary catheterization

bradypnea orthostatic hypotension nausea urinary retention constipation

what effects should the nurse identify as an adverse effect of opioids