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    Hesi lpn exit proctored examQuestion 91
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    Hesi lpn exit proctored exam

    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?

    Explanation & Rationale

    A. Insert the tubing an additional three inches into the rectum: Inserting the tubing further could cause rectal trauma. The standard insertion depth for an adult is 3 to 4 inches, which the PN has already achieved appropriately. B. Instruct the client to take several slow, deep breaths: Deep breathing may help the client relax if there is resistance, but it does not address the lack of flow caused by insufficient gravity pressure in the system. C. Raise the saline container six inches higher: Elevating the container increases gravitational pressure, allowing the enema solution to flow more freely into the rectum. If the tubing is patent and correctly placed, this action restores infusion effectively. D. Re-lubricate the tubing and re-insert it: Re-inserting is unnecessary if the tubing is already properly positioned. Doing so could increase the risk of mucosal injury or contamination without resolving the issue of inadequate height for infusion flow.

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