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 A rationale
A sigmoid colostomy usually produces stool that is more formed compared to an ileostomy. This is because the colostomy is created from the sigmoid colon, where water absorption occurs.
Choice B rationale
The stoma should not be painful after the procedure. Pain may indicate complications, and the stoma itself lacks nerve endings.
Choice C rationale
The stoma should be a bright red or pink color, indicating good blood supply. A purple color could suggest ischemia or poor blood flow.
Choice D rationale
A sigmoid colostomy is typically located in the left lower abdomen because the sigmoid colon is situated in this area of the body.
Correct Answer is C
Explanation
Choice A rationale
Including toilet paper with the collected urine can contaminate the sample and affect the accuracy of the test results.
Choice B rationale
The first void at the start of the collection period should be discarded to ensure that only urine produced during the 24-hour period is collected.
Choice C rationale
Refrigerating the urine during the collection period helps preserve the sample and prevent bacterial growth, which could alter the test results.
Choice D rationale
The last void at the end of the collection period should be included to ensure that the full 24-hour period is accounted for in the collection.