An adult patient has orders for an enema. A nurse will

Give the enema to the patient while he or she sits on the toilet.

Insert the tip of the enema tube into the rectum pointing towards the umbilicus.

Have the patient lie on the right side to facilitate the instillation of water.

Chill the water to a temperature between 75°F and 85°F.

Answer and Explanation

The Correct Answer is B

The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.

Choice A rationale:

Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.

Choice B rationale:

Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.

Choice C rationale:

Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.

Choice D rationale:

Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Addressing the cause of the patient's anxiety and fear is the priority to provide

emotional support and comfort. The nurse should actively listen to the patient's concerns and offer appropriate reassurance and information.

Choice B While assessing the patient's bowel sounds and gas is important for the overall care, it is not the priority at this moment when the patient is expressing fear and anxiety.

Choice C Addressing the family's questions is important, but the patient's emotional wellbeing should be the immediate focus.

Choice D Respiratory assessment is essential but is not the priority when the patient is expressing fear and anxiety about the upcoming surgery.

A. Administering laxatives to the patient B. Preparing to administer a cleansing enema C. Withholding narcotic pain medication for at least 2 hours until the patient had a bowel movement successfully. D. Raising the head of the bed to a semi or high Fowler's position

Correct Answer is D

Explanation

Choice A Laxatives might be an option, but they should not be the first intervention. Other noninvasive measures should be tried first.

Choice B Administering a cleansing enema is not the first intervention for a patient having

trouble defecating into a bedpan. It is an invasive procedure and should be considered after less invasive measures have been tried.

Choice C Withholding pain medication might lead to unnecessary discomfort for the patient and is not the best approach to promote bowel movements.

Choice D Raising the head of the bed will help the patient assume a more upright position, which can facilitate bowel movement and defecation into the bedpan more effectively.

View Question and Answer

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An adult patient has orders for an enema. A nurse will

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Correct Answer is D

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