The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

A. White blood cells (WBCs): The nurse should monitor the client's white blood cell count to assess their ability to withstand exposure to pathogens. WBCs are integral to the body's immune response, as they play a crucial role in defending against infections. An elevated or decreased WBC count can indicate an underlying infection or immune dysfunction, helping the nurse identify potential risks to the client's health. Regular monitoring of WBC levels allows for timely intervention and assessment of the client's immune status.

B. Platelets: Platelets are primarily responsible for blood clotting and are not directly involved in the body's immune response to pathogens. While they are important for hemostasis and preventing excessive bleeding, monitoring platelet count is not directly indicative of a client's ability to withstand exposure to pathogens.

C. Red blood cells: Red blood cells (RBCs) are responsible for transporting oxygen throughout the body and are not directly involved in the immune response to pathogens. Monitoring red blood cell count, hemoglobin, and hematocrit levels is important for assessing oxygen-carrying capacity and detecting conditions such as anemia, but it does not provide specific information about the client's ability to combat infections.

D. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and is used to assess blood volume and oxygen-carrying capacity. While changes in hematocrit levels may indirectly indicate certain health conditions, such as dehydration or polycythemia, it does not directly reflect the client's immune status or ability to withstand exposure to pathogens.