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
Explanation
Cimetidine is a medication known as a histamine H2 receptor antagonist, commonly used in the treatment of peptic ulcer disease. It works by reducing the production of stomach acid. When teaching a client about cimetidine, it is important to inform them about the timing of taking other medications, specifically antacids.
Antacids, which are used to neutralize stomach acid, can interfere with the absorption of cimetidine if taken simultaneously. Therefore, it is generally recommended to wait at least 1 hour after taking cimetidine before taking an antacid. This allows sufficient time for the cimetidine to be absorbed and start working effectively before neutralizing stomach acid with an antacid.
Correct Answer is B
Explanation
This statement is incorrect and requires correction because it suggests starting the flow of urine before positioning the collection container, which can result in contamination of the specimen. The correct procedure for collecting a midstream urine specimen involves the following steps:
1. Provide the client with a clean urine specimen container.
2. Instruct the client to cleanse the genital area using a provided towelette or antiseptic wipes, wiping from front to back.
3. Instruct the client to start urinating into the toilet or bedpan.
4. As the urine stream continues, the client should pass the collection container into the stream to collect the midstream specimen.
5. Once an adequate amount of urine has been collected (as per the laboratory's instructions), the client should remove the container from the stream of urine. 6. The client can then complete urinating into the toilet or bedpan.
The other statements made by the newly licensed nurse are correct:
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion": This statement correctly instructs the client to cleanse the genital area before collecting the urine specimen.
"It will be easier to use your nondominant hand to spread the labia": This statement is correct as it suggests using the nondominant hand to facilitate the collection process.
"Remove the specimen container before stopping the stream of urine": This statement is correct as it indicates that the container should be removed before completing urination.
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