A nurse is preparing to administer an enema to a client.
Which of the following actions should the nurse plan to take?
Place the client into a right lateral position.
Warm the enema solution to room temperature.
Use sterile technique.
Lubricate the tubing with an oil-based lubricant.
The Correct Answer is B
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping, making the procedure less tolerable for the client.
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the solution into the colon.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the absorption of the enema solution. Water-soluble lubricants are preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.
Correct Answer is D
Explanation
Choice A rationale
Collecting two stool specimens from the same area of the stool is incorrect because specimens should be taken from different areas to ensure a representative sample of the stool for testing.
Choice B rationale
Using toilet paper to transfer the stool specimen is not recommended as it can contaminate the sample and interfere with test results.
Choice C rationale
Applying four drops of developing solution to each stool specimen is incorrect. The usual procedure involves applying a specific number of drops as indicated by the test instructions, which may vary.
Choice D rationale
Waiting 30 seconds after applying the developing solution is correct. This waiting period allows the test to react and provide accurate results for the presence of occult blood.
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