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 B
Explanation
Choice A rationale:
Requesting a prescription for a stool softener from the provider could be a potential solution, but it’s not the first step. Medications should be considered when lifestyle modifications and dietary changes are not effective.
Choice B rationale:
Incorporating more fluids and fiber into the patient’s diet is the most appropriate action. Constipation in older adults can be caused by dehydration and not eating enough. Dietary fiber adds bulk to the diet and is capable of absorbing water, which helps to soften the stool and promote regular bowel movements. Therefore, increasing fluid and fiber intake is often the first step in managing constipation.
Choice C rationale:
Encouraging the patient to engage in active range-of-motion exercises might not directly alleviate constipation. While physical activity is generally beneficial for overall health, increased exercise does not improve symptoms of constipation in nursing home residents or older adults.
Choice D rationale:
Advising the patient to avoid foods that cause gas might help if the patient has bloating or gas, but it won’t necessarily address the issue of constipation. The focus should be on increasing fiber and fluid intake.
Correct Answer is ["D"]
Explanation
Choice A rationale:
Petroleum-based ointments like Vaseline are not recommended for moisturizing lips, especially for patients on oxygen therapy. This is because petroleum jelly is not effective at restoring moisture once it’s been lost. Moreover, it can feel heavy and slippery on the lips, and it’s not very eco-friendly.
Choice B rationale:
Oxygen tanks should be kept at a safe distance from heat sources, including electric stoves. However, the recommended distance is not 4 feet but rather at least 5-10 feet away. This is to minimize the risk of fire or combustion.
Choice C rationale:
Wool blankets are not recommended when using oxygen. Wool can cause a spark which can be dangerous around oxygen. It’s important to avoid anything that may cause a spark around home oxygen, including electric heaters, electric blankets, electric razors, hair dryers, or friction toys.
Choice D rationale:
Oxygen tanks should always be stored upright. This prevents any strain on the valves or other components and reduces the risk of damage and potential gas leaks.
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