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:
Collecting urine from the catheter’s port is not the correct procedure when collecting a urine specimen for culture and sensitivity through straight catheterization. The port is not a sterile environment and could contaminate the specimen, leading to inaccurate results.
Choice B rationale:
Using a sterile specimen container is the correct procedure. This ensures that the specimen is not contaminated by any external bacteria or substances, which could affect the results of the culture and sensitivity test. The container must be sterile to prevent the growth of microbes that are not present in the urine sample. This helps to ensure that the results of the culture are accurate and reflect the microbes present in the urine, not those introduced during collection.
Choice C rationale:
Inflating the balloon with sterile water is not a step in this procedure. The balloon is part of an indwelling catheter, not a straight catheter. An indwelling catheter remains in the bladder for a longer period, and the balloon is inflated to keep it in place. A straight catheter is used for a single voiding or to obtain a sterile urine specimen.
Choice D rationale:
Instructing the patient to clean from front to back with an antiseptic solution is not a step in this procedure. While maintaining cleanliness is important, this specific instruction is more relevant to a clean-catch midstream urine specimen, not a specimen collected through straight catheterization.
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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