A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Place the client in the prone position.

Insert the lubricated tip 2.5 cm (1 in) into the anal canal.

Hang the solution bag 7.5 cm (3 in) above the rectum.

Raise the solution bag if the client exhibits pain during the procedure.

Encourage the client to retain the enema solution for 10 min.

Answer and Explanation

Correct Answer : E

A. Place the client in the prone position. The client should be placed in the Sims' (left lateral) position for enema administration.
B. Insert the lubricated tip 2.5 cm (1 in) into the anal canal. The lubricated tip should be inserted 7.5-10 cm (3-4 inches) into the anal canal.
C. Hang the solution bag 7.5 cm (3 in) above the rectum. The solution bag should be hung approximately 30 cm (12 inches) above the rectum.
D. Raise the solution bag if the client exhibits pain during the procedure. The solution bag should be lowered or the flow rate slowed if the client experiences pain.
E. Encourage the client to retain the enema solution for 10 min. Retaining the enema solution for a period of time enhances its effectiveness.

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Correct Answer is D

Explanation

A. Mild, occasional itching: Contact dermatitis usually causes more persistent and sometimes severe itching rather than mild and occasional.
B. Oily skin: Contact dermatitis typically causes dryness and irritation rather than oily skin.
C. Warm hands: Warm hands are not a characteristic finding of contact dermatitis.
D. Scaly patches on the cheeks: This is correct. Contact dermatitis can cause scaly patches, redness, and irritation on the skin, including the cheeks.

A. Secure the cord with electrical tape under area rugs. B. Plug the device into the outlet closest to the tub when bathing. C. Grasp the cord to unplug the device. D. Tape the cord of the device against the baseboard with electrical tape.

Correct Answer is D

Explanation

A. Secure the cord with electrical tape under area rugs. This is incorrect. Securing the cord under rugs can create a fire hazard.
B. Plug the device into the outlet closest to the tub when bathing. This is incorrect and dangerous as water and electricity should never come into contact.
C. Grasp the cord to unplug the device. The correct method is to grasp the plug, not the cord, to avoid damaging the cord and causing a potential electrical hazard.
D. Tape the cord of the device against the baseboard with electrical tape. This is correct. Taping the cord to the baseboard can help prevent tripping hazards and keep the cord secure.

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A nurse is caring for a client who has constipation. Which of the following actions should the nurse take when administering a low-cleansing enema to the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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