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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When the left descending colon and rectum are removed, a colostomy is typically created. This involves bringing the proximal end of the remaining colon to the surface of the abdomen to create a stoma. The colostomy allows the rest of the bowel to heal and function normally.
B.A continent ostomy involves creating an internal reservoir with a valve, allowing the patient to control the evacuation of intestinal contents. This option is less common and usually associated with continent ileostomies rather than temporary diversions to rest a portion of the colon.
C. A Kock pouch is a type of continent ileostomy where an internal reservoir is created from the ileum, and the patient can empty the reservoir with a catheter. This is not typically used as a diversion for healing purposes involving the colon.
D.An ileostomy involves bringing the end of the ileum (the last part of the small intestine) to the surface of the abdomen to create a stoma. Given that the left descending colon and rectum were removed, this procedure is unlikely unless the entire colon is bypassed or removed, which is not specified in this scenario.
Correct Answer is A
Explanation
Choice A: Bright red stool can be caused by various factors, including the consumption of certain foods, medications, or gastrointestinal bleeding. Stress can lead to changes in bowel movements and might cause bright red stool due to increased gastrointestinal motility.
Choice B: While it's essential to reassure the patient, dismissing their concern without further assessment is not appropriate. The nurse should still investigate the potential causes of bright red stool.
Choice C: Jumping to conclusions and ordering immediate tests without further assessment is not the best approach. Before taking any action, the nurse should gather more information and assess other possible causes.
Choice D: Suggesting a colonoscopy as the first step is not necessary for every case of bright red stool. Further assessment is needed to determine the cause before resorting to such an invasive procedure.
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