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 B

Explanation

A. "I feel so much better after eating."This is most consistent with a duodenal ulcer, where pain is relieved by food (but often returns 2–3 hours later). Gastric ulcers, on the other hand, may worsen with eating.

B. "The pain is worse after I eat a meal high in fat."Fatty food intolerance and postprandial pain are more characteristic of gallbladder disease (cholelithiasis/cholecystitis), not PUD.

C. "The pain radiates down to my lower back."Pain radiating to the back is more typical of pancreatitis, not PUD.

D. "My pain is relieved by having a bowel movement."Relief of abdominal pain with a bowel movement suggests irritable bowel syndrome (IBS), not PUD.

A. Take the medication on an empty stomach. B. Muscle weakness is an expected adverse effect. C. Increase daily intake of foods high in potassium. D. Take the medication at bedtime.

Correct Answer is C

Explanation

Hydrochlorothiazide is a thiazide diuretic commonly used to treat hypertension and edema. One of the potential side effects of hydrochlorothiazide is hypokalemia (low potassium levels). To help counteract this effect, it is important for the client to increase their daily intake of foods high in potassium, such as bananas, oranges, spinach, avocados, and potatoes. This helps maintain adequate potassium levels in the body.

The other options mentioned are incorrect:

Take the medication on an empty stomach: Hydrochlorothiazide can be taken with or without food. It does not need to be taken on an empty stomach.

Muscle weakness is an expected adverse effect: Muscle weakness is not a common or expected adverse effect of hydrochlorothiazide. If the client experiences muscle weakness, they should notify their healthcare provider.

Take the medication at bedtime: Hydrochlorothiazide can be taken at any time of the day. There is no specific requirement to take it at bedtime. The dosing schedule should be determined based on the individual's needs and healthcare provider's instructions.

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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

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