A nurse is caring for a patient who reports constipation.
The doctor has ordered an enema.
Identify the sequence of steps the nurse should follow to administer the enema.
Assisting the patient into the Sims’ position
Confirm the patient’s identity by checking their wristband.
Provide privacy for the patient by closing the curtains.
Insert the tip of the enema tubing into the patient’s rectum.
The Correct Answer is B,C,A,D
B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.
C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.
A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.
D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced. It occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This condition does not directly cause dry skin.
Choice B rationale:
Abdominal pain is not a common symptom of respiratory alkalosis. The condition is usually caused by over-breathing (called hyperventilation) that occurs when you breathe very deeply or rapidly. While it can cause discomfort, it does not typically result in abdominal pain.
Choice C rationale:
Diarrhea is not a direct symptom of respiratory alkalosis. However, the stress or anxiety that can cause hyperventilation and lead to respiratory alkalosis might also upset the digestive system and cause diarrhea. It’s important to note that while stress and anxiety can cause both conditions, they are not a direct result of the respiratory alkalosis itself.
Choice D rationale:
Flank pain is not a symptom of respiratory alkalosis. Flank pain is often associated with kidney problems, not respiratory conditions. Respiratory alkalosis is characterized by symptoms such as dizziness, bloating, feeling light-headed, numbness or muscle spasms in the hands and feet, discomfort in the chest area, confusion, dry mouth, tingling in the arms, heart palpitations, and feeling short of breath.
Correct Answer is ["C"]
Explanation
The correct answer is Choice C.
Choice A rationale: Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
Choice B rationale: Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
Choice C rationale: Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
Choice D rationale: Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
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