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 ["B","D"]
Explanation
When reinforcing teaching with a client who has a duodenal ulcer and a new prescription for cimetidine, the nurse should include the following instructions:
"Avoid taking the medication at bedtime.": Cimetidine is most effective when taken during waking hours to help control gastric acid secretion. Taking it at bedtime may not provide optimal therapeutic benefits.
"You will need to continue taking this medication for up to 6 weeks.": Cimetidine is often prescribed for the treatment of duodenal ulcers and may require several weeks of continuous use to promote healing. It is important for the client to understand the duration of treatment and the need for adherence to the prescribed regimen.
The following statements are incorrect or not applicable:
"Drinking grapefruit juice while taking cimetidine can lead to toxicity.": Cimetidine does not have a known interaction with grapefruit juice. However, it is always important to consult the healthcare provider or pharmacist about potential drug interactions, including those related to specific foods or beverages.
"Take an antacid 30 minutes prior to taking cimetidine to minimize stomach upset.": Cimetidine is an H2 receptor antagonist that works by reducing stomach acid production. It is not necessary to take an antacid prior to taking cimetidine to minimize stomach upset. However, if the client experiences stomach upset or discomfort, they should consult their healthcare provider for further guidance on managing these symptoms.
Correct Answer is A,B,C,D,E,F
Explanation
To prepare a sterile field for the insertion of a urinary catheter, the nurse should follow the sequence of actions in the following order:
1. Perform hand hygiene.
2. Place the sterile package on the work surface.
3. Open the outermost flap of the package away from the body.
4. Open the side flaps of the package.
5. Open the innermost flap of the package toward the body.
6. Use the inner surface of the package as a sterile field.
Following this sequence ensures that the nurse maintains proper hand hygiene, prepares the sterile package, and opens it in a way that maintains sterility. Opening the flaps in the correct order helps create a sterile field within the package, which can be used for the insertion of the urinary catheter.
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