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 ["A","D"]
Explanation
From the given statements, the nurse can identify the following statements as indicating the effectiveness of cimetidine treatment:
"I don't have as much heartburn after I eat anymore.": Cimetidine is a histamine-2 receptor antagonist commonly used to reduce stomach acid production. Decreased heartburn after eating suggests that the medication has been effective in reducing excessive acid production and relieving heartburn symptoms.
"I can sleep while lying flat again.": Cimetidine can help alleviate symptoms of gastroesophageal reflux disease (GERD) by reducing stomach acid. Improved ability to sleep while lying flat suggests that the medication has successfully reduced acid reflux and related symptoms.
The following statements do not directly indicate the effectiveness of cimetidine treatment: ● "I noticed that I have had less urge to smoke lately."
● "I occasionally have stomach pain and dark stools."
● "I have not been as dizzy as I was before."
These statements may be unrelated to the effects of cimetidine or may require further assessment to determine their significance. It's important for the nurse to address any concerns or symptoms mentioned by the client and evaluate their overall response to the medication
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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