What is the preferred client position for an enema?
Lithotomy.
Supine.
Semi-Fowler's.
Left Sims'.
The Correct Answer is D
Choice A rationale
The lithotomy position involves the client lying on their back with hips and knees flexed and thighs apart, often supported in stirrups. This position is primarily used for vaginal examinations, childbirth, or urological procedures. It does not facilitate the natural flow of enema solution into the sigmoid colon and rectum. Furthermore, this position can be uncomfortable and does not utilize gravity to assist in the distribution of the fluid throughout the lower descending colon segment.
Choice B rationale
The supine position, where the client lies flat on their back, is inappropriate for enema administration. In this position, the rectum is not aligned to allow for the easy passage of the rectal tube or the efficient flow of the enema solution. Gravity would work against the fluid moving deeper into the colon, likely resulting in poor retention and ineffective results. It also increases the risk of the client feeling immediate pressure and expelling the fluid prematurely.
Choice C rationale
Semi-Fowler's position involves the client sitting up with the head of the bed at a 30 to 45 degree angle. This position is typically used to promote lung expansion or reduce the risk of aspiration. It is not suitable for enema administration because the upright angle of the torso makes it difficult to access the rectum properly. Additionally, gravity would cause the fluid to pool in the rectum rather than flowing higher into the sigmoid colon for cleansing.
Choice D rationale
Left Sims' position, where the client lies on the left side with the right knee flexed toward the chest, is the preferred position for an enema. This position allows the enema solution to flow by gravity along the natural curve of the sigmoid colon and the descending colon. This facilitates deeper penetration of the fluid and better retention, leading to more effective bowel stimulation. It also provides the nurse with optimal visualization and access to the anal area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Taking a fire extinguisher to the room follows the acronym PASS, but in the sequence of fire safety represented by the acronym RACE, extinguishing the fire is the very last step. The nurse must first ensure that the alarm is sounded to alert the entire facility and the fire department. Attempting to fight a fire before the alarm is activated could lead to the fire spreading unnoticed by others, which puts the entire building and all occupants at risk.
Choice B rationale
While calling 911 is an important part of emergency response, pulling the fire alarm is a faster and more efficient way to alert all personnel in a hospital setting. The fire alarm system is often directly linked to the fire department and simultaneously activates internal alerts and fire doors. Relying solely on a phone call may delay the immediate localized response needed to contain the situation. The alarm ensures that the specific location of the fire is identified.
Choice C rationale
According to the RACE acronym, which stands for Rescue, Alarm, Confine, and Extinguish, the second action after rescuing the client is to activate the fire alarm. This ensures that the fire department is notified and that all staff members are aware of the emergency. Promptly pulling the alarm allows the facility to begin its established fire protocols, which are essential for the safety of everyone in the building. It is the most critical next step.
Choice D rationale
Evacuating all clients on the nursing unit is a later step in the fire safety protocol, typically occurring if the fire cannot be contained or if ordered by the fire marshal. The immediate priority after removing the person in danger is to sound the alarm. Evacuation is a complex and high-risk process that should be coordinated based on the severity and location of the fire. Moving too many people prematurely can create chaos and block the access of emergency responders.
Correct Answer is B
Explanation
Choice A rationale
Pyuria refers to the presence of white blood cells or pus in the urine, which typically indicates an underlying urinary tract infection or inflammatory process. Normal urine should be clear and generally free of significant leukocyte counts, usually less than 2 to 5 white blood cells per high power field. Pyuria is a qualitative description of urine content rather than a quantitative measure of the total volume produced by the kidneys over a twenty-four-hour period.
Choice B rationale
Anuria is defined as a total urine output of less than 50 mL or 100 mL in a 24-hour period, often signifying complete kidney failure or a major obstructive event. In a healthy adult, the kidneys should produce significantly more, with a normal 24-hour output ranging between 800 and 2000 mL depending on fluid intake. Anuria is a critical clinical finding that requires immediate medical intervention to address the cessation of waste excretion and fluid balance.
Choice C rationale
Oliguria is characterized by a diminished capacity to produce urine, typically defined as an output of less than 400 mL but more than 100 mL over 24 hours in an adult. While it indicates significant renal impairment or dehydration, it is not as severe as anuria. Normal kidney function involves filtering the entire blood volume many times a day, and an output falling below 400 mL suggests the kidneys cannot effectively clear metabolic waste products.
Choice D rationale
Glycosuria is the medical term for the excretion of glucose in the urine, which commonly occurs when blood glucose levels exceed the renal threshold of approximately 180 mg/dL. In a healthy individual, the urine should contain no glucose because the kidneys reabsorb it back into the bloodstream. Like pyuria, glycosuria describes the chemical composition of the urine rather than the total volume produced, making it irrelevant to the specific definition of low urine output levels.
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