An adult patient has orders for an enema. A nurse will
Give the enema to the patient while he or she sits on the toilet.
Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Have the patient lie on the right side to facilitate the instillation of water.
Chill the water to a temperature between 75°F and 85°F.
The Correct Answer is B
The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Choice A rationale:
Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.
Choice B rationale:
Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.
Choice C rationale:
Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.
Choice D rationale:
Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A The shape of the abdomen is a physical assessment finding and not subjective
information provided by the patient. It involves the nurse's observation of the patient's abdomen during the examination.
Choice B Bowel sounds are also physical assessment findings that involve the nurse listening to the patient's abdomen using a stethoscope.
Choice C This is the correct answer. Abdominal cramping and discomfort are subjective symptoms reported by the patient and are relevant to the patient's bowel elimination status. Choice D Like the shape of the abdomen, the distention of the abdomen is a physical assessment finding and not subjective information provided by the patient.
Correct Answer is B
Explanation
ChoiceA: This volume might be insufficient for a large volume, cleansing enema, as it may not effectively cleanse the colon.
Choice: This range is the appropriate volume for a large volume, cleansing enema, as it provides enough fluid to cleanse the colon effectively without causing excessive distension.
Choice C: This volume is too low for a large volume, cleansing enema, and it may not be enough to achieve the desired effect.
Choice D: This volume is too low for a large volume, cleansing enema, and it may not effectively cleanse the colon.
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