A nurse is preparing to administer an enema to a client.
Which of the following actions should the nurse plan to take?
Place the client into a right lateral position.
Warm the enema solution to room temperature.
Use sterile technique.
Lubricate the tubing with an oil-based lubricant.
The Correct Answer is B
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
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Correct Answer is B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is D
Explanation
Choice A rationale
It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.
Choice B rationale
Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.
Choice C rationale
Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.
Choice D rationale
Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.