A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
Hold the container of solution 30 cm (12 in) above the anus.
Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
Hold the container of solution level with the client's upper hip.
Keep the container of solution at a level to maintain client comfort.
The Correct Answer is A
A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.
Correct Answer is D
Explanation
A. Dehydration is unlikely to cause blood-tinged urine. Dehydration can lead to concentrated urine, but it typically does not cause blood in the urine.
B. Pernicious anemia is a condition related to a deficiency in vitamin B12, which can lead to a decrease in red blood cell production. However, it is not directly associated with blood in the urine.
C. Bladder infection can cause blood in the urine, but it is more commonly associated with symptoms such as urinary frequency, urgency, and burning during urination. If blood is present, it is usually due to inflammation of the bladder lining.
D. Prostate enlargement, also known as benign prostatic hyperplasia (BPH), can cause blood-tinged urine. The prostate gland surrounds the urethra, and enlargement can lead to irritation and bleeding from the urinary tract.
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