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

Warm the enema solution to room temperature.

Use sterile technique

Place the client into a right lateral position.

Lubricate the tubing with an oil-based lubricant.

Answer and Explanation

The Correct Answer is A

A. Warm the enema solution to prevent discomfort and potential injury from a cold solution.

B. Clean technique is used when administering enemas, not sterile technique.

C. The left lateral position is preferred for enema administration.

D. An oil-based lubricant is not recommended for enema tubing; a water-based lubricant is preferred.

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Correct Answer is A

Explanation

A. Decreased heart rate: Bearing down (Valsalva maneuver) can stimulate the vagus nerve, leading to a decrease in heart rate.

B. Increased respirations: Respirations may not increase during the Valsalva maneuver but rather may temporarily decrease or become irregular.

C. Increased temperature: No direct link exists between the Valsalva maneuver and temperature changes.

D. Decreased exhaled carbon dioxide: Valsalva may lead to transient changes in exhaled CO2, but decreased heart rate is the more immediate concern.

A. Pacing B. Restless C. Alert D. Anxiety

Correct Answer is D

Explanation

A. Pacing is an objective finding as it can be directly observed by the nurse during the assessment.

B. Restlessness is considered an objective finding because it is a behavior the nurse can identify through observation.

C. Alertness is also an objective finding, as it can be assessed through interaction with the client.

D. Anxiety is a subjective finding, as it is based on the client’s personal experience and self-report, which cannot be directly observed.

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

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