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 D
Explanation
Choice D rationale
Dark-colored urine is a common indicator of dehydration. When the body is dehydrated, urine becomes more concentrated, leading to darker color due to higher levels of waste products.
Choice A rationale
Cloudy urine is not typically associated with dehydration. It may indicate the presence of an infection, inflammation, or other medical conditions.
Choice B rationale
Urine osmolality of 200 mOsm/kg suggests diluted urine, which is contrary to the expectation in dehydration. Dehydration would typically result in higher urine osmolality as the kidneys conserve water.
Choice C rationale
Urine specific gravity of 1.015 falls within the normal range (1.005 to 1.030). In dehydration, specific gravity would be expected to be higher as the urine becomes more concentrated to conserve water.
Correct Answer is C
Explanation
Choice C rationale
The large intestine absorbs water and electrolytes from the remaining indigestible food matter, forming and eliminating solid waste (stool). This absorption process is vital for
maintaining the body's fluid and electrolyte balance.
Choice A rationale
The large intestine does not produce vitamin D; this occurs in the skin when exposed to sunlight. The large intestine’s primary functions are absorption and waste formation.
Choice B rationale
Preventing the reflux of food into the esophagus is the function of the lower esophageal sphincter, not the large intestine. The large intestine deals with waste processing rather than regulating esophageal function.
Choice D rationale
The secretion of digestive enzymes is a function of the pancreas, stomach, and small intestine. The large intestine does not secrete enzymes but focuses on absorbing water and electrolytes.