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 A
Explanation
The purpose of the stool guaiac test, also known as the fecal occult blood test (FOBT), is to identify the presence of hidden or occult blood in the stool. This test is commonly performed to screen for gastrointestinal bleeding, which can indicate various conditions such as colorectal cancer, ulcers, polyps, or other sources of bleeding in the digestive tract.
The other options mentioned are not specifically detected by the stool guaiac test:
Parasites: The stool guaiac test does not directly detect parasites in the feces. Parasite testing requires a different type of analysis, such as microscopic examination or specialized laboratory tests.
Bacteria: The stool guaiac test does not specifically detect bacteria in the feces. If a bacterial infection is suspected, other diagnostic tests such as stool culture or polymerase chain reaction (PCR) may be ordered.
Fat: The stool guaiac test is not designed to detect fat in the feces. If there is a concern about fat malabsorption, other tests such as fecal fat analysis or Sudan stain may be used.
Correct Answer is A
Explanation
The manifestation of gastrointestinal perforation includes severe upper abdominal pain. This can be a significant symptom indicating a potential perforation in the gastrointestinal tract. It is important to note that gastrointestinal perforation is a medical emergency that requires immediate attention and intervention.
Hyperactive bowel sounds: This finding is more commonly associated with conditions like bowel obstruction or gastroenteritis rather than gastrointestinal perforation.
Bradycardia: Bradycardia (slower than normal heart rate) is not a typical manifestation of gastrointestinal perforation. It may be associated with other conditions or factors.
Report of epigastric fullness: Epigastric fullness can be a symptom of various gastrointestinal conditions, including peptic ulcer disease itself. However, it is not a specific manifestation of gastrointestinal perforation.
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