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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.
By measuring gastric residual, the nurse can:
● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.
● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.
● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.
Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.
While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.
Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.
Correct Answer is A
Explanation
Docusate is a stool softener commonly used to relieve constipation. Opioid pain medications often cause constipation as a side effect by slowing down bowel movements. Docusate helps by increasing the amount of water absorbed by the stool, making it softer and easier to pass.
The other options mentioned are not the primary therapeutic effects of docusate: Relief from nausea: Docusate is not typically prescribed for relief from nausea. Antiemetic medications are used to alleviate nausea and vomiting.
Decreased drowsiness: Docusate does not directly affect drowsiness. Its main action is on the stool consistency, not on alertness or drowsiness.
Decreased cancer pain: Docusate is not prescribed for pain relief. Opioids are generally used to manage cancer pain in this scenario.
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