A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Insert the tubing about 15 cm (6 in) into the anus.

Hang the enema container 61 cm (24 in) above the anus.

Assist the client to the left Sims' position.

Put on sterile gloves.

Answer and Explanation

The Correct Answer is C

The left Sims' position (also known as the left lateral position) is the appropriate position for administering a soapsuds enema. This position allows for better visualization and access to the rectum and facilitates the flow of the enema solution.

The other options mentioned are incorrect:

Inserting the tubing about 15 cm (6 in) into the anus: The specific depth of insertion may vary depending on the client, but the general guideline is to insert the tubing about 3 to 4 inches into the rectum for an adult. 15 cm (6 in) would be excessively deep and could cause discomfort or injury.

Hanging the enema container 61 cm (24 in) above the anus: The height at which the enema container is hung should be no more than 18-24 inches (45-60 cm) above the anus. Hanging it too high can cause excessive pressure and discomfort during the administration.

Putting on sterile gloves: Sterile gloves are not typically required for the administration of a soapsuds enema. Clean gloves or non-sterile gloves are generally sufficient for this procedure.

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Correct Answer is ["13"]

Explanation

To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:

Volume to be infused: 1,200 ml

Drop factor: 15 gtt/ml

Time: 24 hr

First, we need to convert the time from hours to minutes:

24 hr * 60 min/hr = 1,440 min

Now, we can calculate the infusion rate:

Infusion rate (gtt/min) = (1,200 ml * 15 gtt/ml) / 1,440 min

Simplifying the equation:

Infusion rate (gtt/min) = 18,000 gtt / 1,440 min

Dividing both sides:

Infusion rate (gtt/min) ≈ 12.5 gtt/min

Rounding the answer to the nearest whole number, the nurse should set the manual IV infusion to deliver approximately 13 gtt/min.

A. Remove the bottle cap. B. Place the bottle cap inside up on clean surface. C. Pick up the bottle with the label facing his palm. D. Pour 1 to 2 mL into a receptacle. E. Pour the solution onto the gauze.

Correct Answer is C,A,D,E,B

Explanation

To pour the sterile solution onto a piece of gauze, the nurse should perform the steps in the following order:

1. Pick up the bottle with the label facing his palm.

2. Remove the bottle cap.

3. Pour 1 to 2 mL into a receptacle.

4. Pour the solution onto the gauze.

5. Place the bottle cap inside up on a clean surface.

It is important to maintain sterility throughout the procedure to prevent contamination. By following this order, the nurse ensures that the solution is poured onto the gauze while minimizing the risk of contamination. Placing the bottle cap inside up on a clean surface after removing it helps maintain the sterility of the cap as well.

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A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["13"]

Explanation

A nurse assisting a provider with a sterile procedure prepares to pour a sterile solution onto a piece of gauze. In which order should the nurse perform the steps of pouring the solution? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,A,D,E,B

Explanation

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