A nurse is preparing to administer an enema to a client. Which of the following actions should the nurse plan to take?
Warm the enema solution to room temperature.
Use sterile technique
Place the client into a right lateral position.
Lubricate the tubing with an oil-based lubricant.
The Correct Answer is A
A. Warm the enema solution to prevent discomfort and potential injury from a cold solution.
B. Clean technique is used when administering enemas, not sterile technique.
C. The left lateral position is preferred for enema administration.
D. An oil-based lubricant is not recommended for enema tubing; a water-based lubricant is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","H"]
Explanation
ANSWERED:
Day 1:
- Abdomen soft, nondistended.
- Ileostomy present. Stoma is red.
- Stoma draining brown liquid stool.
- Client will not look at stoma
- Client states they are not interested in learning about stoma care.
Day 2:
- Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.
- Stoma with small amount of bleeding noted during cleaning.
Rationale:
Findings requiring intervention
Client will not look at stoma: This indicates potential emotional distress, denial, or difficulty adjusting to the ileostomy. The nurse should address these concerns by providing emotional support and encouraging gradual acceptance of the stoma through education and therapeutic communication.
Client states they are not interested in learning about stoma care: A lack of interest in learning stoma care poses a barrier to self-care and independence. The nurse should explore the client’s feelings, provide gentle encouragement, and offer step-by-step guidance to build their confidence.
Skin surrounding stoma reddened and has small open areas: Redness and open areas suggest irritation or breakdown of peristomal skin, likely due to improper pouch application or leakage. The nurse should assess the fit of the ileostomy pouch, recommend barrier creams, and consult a wound care specialist if needed.
Findings not requiring intervention
Abdomen soft, nondistended: This finding is normal and does not indicate any issues requiring intervention.
Stoma is red: A healthy stoma is typically moist, red, and similar in appearance to the inside of the mouth. This finding is expected.
Stoma draining brown liquid stool: Brown liquid stool is a normal output for an ileostomy and does not require intervention.
Stoma with small amount of bleeding noted during cleaning: Minimal bleeding from the stoma is common during cleaning or manipulation, especially early postoperatively. This is generally not a concern unless the bleeding is excessive or persistent.
Correct Answer is C
Explanation
A. Postoperative respiratory function may improve with proper teaching.
B. Postoperative pain should be managed, not increased.
C. Preoperative teaching helps reduce anxiety by preparing the client for the procedure.
D. Preoperative teaching can reduce the length of postoperative care.
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