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 ["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
Correct Answer is A
Explanation
When reinforcing teaching with a client who has a new prescription for aluminum hydroxide to treat heartburn, the nurse should include constipation as an adverse effect of the medication. Aluminum hydroxide is an antacid commonly used to neutralize stomach acid and provide relief from heartburn and indigestion. However, one of its potential side effects is constipation. Aluminum hydroxide can slow down intestinal motility, leading to infrequent or difficult bowel movements.
Hypertension: Aluminum hydroxide is not known to cause hypertension (high blood pressure). However, clients with pre-existing hypertension should be cautious when using antacids containing sodium bicarbonate, as the sodium content may impact blood pressure levels.
Flatulence: Flatulence (excessive gas) is not a common adverse effect of aluminum hydroxide. It primarily works by neutralizing stomach acid and does not typically cause increased gas production.
Headache: Headache is not commonly reported as an adverse effect of aluminum hydroxide. It is more likely to be associated with other factors such as the underlying condition causing heartburn or individual factors.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today