A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Insert the tubing about 15 cm (6 in) into the anus.

Hang the enema container 61 cm (24 in) above the anus.

Assist the client to the left Sims' position.

Put on sterile gloves.

Answer and Explanation

The Correct Answer is C

The left Sims' position (also known as the left lateral position) is the appropriate position for administering a soapsuds enema. This position allows for better visualization and access to the rectum and facilitates the flow of the enema solution.

The other options mentioned are incorrect:

Inserting the tubing about 15 cm (6 in) into the anus: The specific depth of insertion may vary depending on the client, but the general guideline is to insert the tubing about 3 to 4 inches into the rectum for an adult. 15 cm (6 in) would be excessively deep and could cause discomfort or injury.

Hanging the enema container 61 cm (24 in) above the anus: The height at which the enema container is hung should be no more than 18-24 inches (45-60 cm) above the anus. Hanging it too high can cause excessive pressure and discomfort during the administration.

Putting on sterile gloves: Sterile gloves are not typically required for the administration of a soapsuds enema. Clean gloves or non-sterile gloves are generally sufficient for this procedure.

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Correct Answer is B

Explanation

Furosemide is a loop diuretic commonly prescribed for conditions such as hypertension and edema. One of the side effects of furosemide is the increased excretion of potassium in the urine, which can lead to low potassium levels in the body, known as hypokalemia. The other medications mentioned do not typically place the client at risk for hypokalemia: Acyclovir 400 mg PO twice daily: Acyclovir is an antiviral medication used to treat viral infections, such as herpes. It does not have a direct effect on potassium levels. Cimetidine 300 mg PO four times per day: Cimetidine is a histamine H2 receptor antagonist commonly used to reduce stomach acid production. It does not have a direct effect on potassium levels.

Meloxicam 5 mg PO once daily: Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief. It does not have a direct effect on potassium levels.

Correct Answer is ["25"]

Explanation

To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:

Volume to be infused: 100 ml

Drop factor: 60 gtt/ml

Time: 4 hr

First, we need to convert the time from hours to minutes:

4 hr * 60 min/hr = 240 min

Now, we can calculate the infusion rate:

Infusion rate (gtt/min) = (100 ml * 60 gtt/ml) / 240 min

Simplifying the equation:

Infusion rate (gtt/min) = 6000 gtt / 240 min

Dividing both sides:

Infusion rate (gtt/min) ≈ 25 gtt/min

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A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia?

Correct Answer is B

Explanation

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

Correct Answer is ["25"]

Explanation

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