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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Neobladder urinary diversion involves creating an internal reservoir or pouch from a segment of the intestine to store urine. This new bladder is then connected to the urethra,
enabling the client to void through the urethra. This method closely mimics natural urination, allowing the client to have some control over urination.
Choice B rationale
This is incorrect because a neobladder is designed to allow the client to control urination. While there might be a learning curve for the client to adapt to the new bladder, the ultimate
goal is to achieve continence.
Choice C rationale
This describes an ileal conduit, another type of urinary diversion, where a stoma is created on the abdomen for urine to pass into an external bag. The neobladder does not involve a
stoma for urination.
Choice D rationale
This is incorrect as it pertains to an ileal conduit or urostomy. Clients with a neobladder do not require an external collection bag since urine is stored internally in the constructed
bladder and can be passed through the urethra. .
Correct Answer is D
Explanation
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.