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 D

Explanation

When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.

The other options mentioned are incorrect:

Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.

Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.

Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.

A. Take the medication with an antacid B. Take the medication 1 hr before meals C. Take as needed for pain relief D. Store the medication in the refrigerator

Correct Answer is B

Explanation

Sucralfate is a medication commonly used in the treatment of peptic ulcer disease. It works by forming a protective barrier over the ulcer site, providing a physical barrier against gastric acid, and promoting the healing process. When teaching a client about sucralfate, it is important to provide instructions regarding its proper administration.

One of the key instructions is to take sucralfate 1 hour before meals. This timing allows the medication to form a protective coating in the stomach before food is ingested. Taking sucralfate on an empty stomach enhances its effectiveness in protecting the ulcer and promoting healing.

"Take the medication with an antacid" - Sucralfate should not be taken with an antacid. Antacids can interfere with the protective mechanism of sucralfate by neutralizing stomach acid, which is necessary for sucralfate to bind and form a protective coating. It is recommended to wait at least 30 minutes to 1 hour after taking sucralfate before taking an antacid.

"Take as needed for pain relief" - Sucralfate is not typically used for immediate pain relief in peptic ulcer disease. It is primarily used for its protective and healing properties. Pain relief is

usually addressed with other medications, such as antacids, acid-reducing medications, or pain medications as prescribed by a healthcare provider.

"Store the medication in the refrigerator" - Sucralfate does not require refrigeration. It should be stored at room temperature, away from excessive heat or moisture, as per the specific instructions provided by the manufacturer or healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1000 mL to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

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