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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Cimetidine is a medication known as a histamine H2 receptor antagonist, commonly used in the treatment of peptic ulcer disease. It works by reducing the production of stomach acid. When teaching a client about cimetidine, it is important to inform them about the timing of taking other medications, specifically antacids.
Antacids, which are used to neutralize stomach acid, can interfere with the absorption of cimetidine if taken simultaneously. Therefore, it is generally recommended to wait at least 1 hour after taking cimetidine before taking an antacid. This allows sufficient time for the cimetidine to be absorbed and start working effectively before neutralizing stomach acid with an antacid.
Correct Answer is A
Explanation
Metoclopramide is a medication commonly used to treat gastrointestinal disorders such as gastroesophageal reflux disease (GERD). While it is generally well-tolerated, it can have some adverse effects. Sedation is one of the common side effects of metoclopramide. It can cause drowsiness, dizziness, and a feeling of tiredness in some individuals. Therefore, the nurse should monitor the client for any signs of sedation or excessive drowsiness, especially when the client starts taking the medication or when the dose is increased.
Hypertension: Metoclopramide is not known to cause hypertension (high blood pressure) as a common side effect. In fact, it may have a mild hypotensive (blood pressure-lowering) effect in some individuals.
Urinary retention: Metoclopramide does not typically cause urinary retention. Instead, it can enhance gastrointestinal motility and increase the frequency of bowel movements.
Blurred vision: While visual disturbances are rare adverse effects of metoclopramide, blurred vision is not a commonly reported side effect. However, other visual disturbances like oculogyric crisis (involuntary rolling back of the eyes) have been reported in rare cases. Nevertheless, monitoring for blurred vision specifically is not a priority when administering metoclopramide.
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