The nurse is preparing to administer a soapsuds enema to a client. Which position should the client be in to administer the enema?

Position A

Position B

Position C

Position D

Answer and Explanation

The Correct Answer is A

Choice A rationale
The most common position for administering an enema is the left lateral position, where the patient lies on their left side with their right leg flexed toward their chest. This position allows for the best flow of the enema solution by gravity along the natural curves of the sigmoid colon and rectum.
Choice B rationale
Position B is not typically recommended for enema administration.
Choice C rationale
Position C is not typically recommended for enema administration.
Choice D rationale
Position D is not typically recommended for enema administration

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Correct Answer is C

Explanation

Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice B rationale
Hyperactive bowel sounds are not typically a sign of gastrointestinal perforation in peptic ulcer disease25.
Choice C rationale
Severe upper abdominal pain is a common sign of gastrointestinal perforation in peptic ulcer disease25. The pain is often sudden and severe, and it may spread to the back or shoulder.
Choice D rationale
A report of epigastric fullness is not typically a sign of gastrointestinal perforation in peptic ulcer disease25.

A. Assure the patient the problem is temporary. B. Cut the food into small pieces. C. Report the observation to the healthcare provider (HCP). D. Offer the patient liquids instead.

Correct Answer is C

Explanation

Choice A rationale
Assuring the patient that the problem is temporary may not be accurate. Postoperative dysphagia could indicate a complication from the surgery, such as the stomach fundus being wrapped too tight around the esophagus, causing food obstruction. It’s important to not dismiss the patient’s concerns without proper assessment.
Choice B rationale
Cutting the food into small pieces might help the patient swallow easier, but it does not address the underlying issue. The patient’s difficulty in swallowing could be a sign of a serious problem that needs medical attention.
Choice C rationale
Reporting the observation to the healthcare provider (HCP) is the correct action. After the repair of a paraesophageal hernia, dysphagia should be reported to the HCP. The corrective fundoplication surgery may have the stomach fundus wrapped too tight around the esophagus, causing food obstruction.
Choice D rationale

Offering the patient liquids instead might alleviate the symptom temporarily, but it does not solve the potential problem. The healthcare provider needs to be informed about the dysphagia to assess and treat the possible complication.

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The nurse is preparing to administer a soapsuds enema to a client. Which position should the client be in to administer the enema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering data from a client who has peptic ulcer disease. Which of the following findings is a sign of gastrointestinal perforation?

Correct Answer is C

Explanation

The nurse is providing care for a patient who had surgical repair of a paraesophageal (rolling) hernia. The nurse observes that the patient is having difficulty swallowing during the first postoperative meal.What action should the nurse take?

Correct Answer is C

Explanation

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