Which word should the nurse use when describing to a client how a soapsuds enema affects the intestine?

Lubricating

Irritating

Dilating

Softening

Answer and Explanation

The Correct Answer is B

A. Lubricating: A lubricating enema typically refers to an enema solution that contains a lubricant, such as mineral oil, to help soften feces and facilitate their passage from the rectum. Lubricating enemas are used to alleviate constipation by easing the passage of stool. However, soapsuds enemas do not primarily function as lubricating enemas.

B. Irritating: This is the correct option. Soapsuds enemas contain soap or detergent mixed with water, and their primary action is to irritate the intestinal mucosa. The irritation stimulates peristalsis, which promotes bowel evacuation. Soapsuds enemas are often used to relieve constipation by inducing bowel movements through irritation of the intestinal lining.

C. Dilating: Dilating refers to widening or enlarging a structure. While enemas, including soapsuds enemas, may contribute to the relaxation and dilation of the rectum and lower bowel, the primary action of a soapsuds enema is to stimulate bowel evacuation through irritation rather than dilation.

D. Softening: Softening enemas typically involve the introduction of a solution, such as a mineral oil-based solution, to soften feces and facilitate their passage from the rectum. While softening enemas help alleviate constipation by softening stool consistency, soapsuds enemas do not primarily function as softening enemas. Their main action is to stimulate bowel evacuation through irritation.

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Correct Answer is ["B","E"]

Explanation

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

A. 4 in. (10.2 cm) B. 5 in (12.7 cm) C. 6 in. (15.25 cm) D. 2 in. (5.1 cm) E. 3 in. (7.6 cm)

Correct Answer is ["A","E"]

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

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Which word should the nurse use when describing to a client how a soapsuds enema affects the intestine?

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Naxlex Comprehensive Predictor Exams

The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

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)

Correct Answer is ["A","E"]

Explanation

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