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A nurse is preparing to administer an enema to a client.
Which of the following actions should the nurse plan to take?

A.

Place the client into a right lateral position.

B.

Warm the enema solution to room temperature.

C.

Use sterile technique.

D.

Lubricate the tubing with an oil-based lubricant.

Answer and Explanation

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

Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.

Choice B rationale

Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.

Choice C rationale

Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.

Choice D rationale

Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.

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