Nokea
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. When the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next?
- A. Elevating the head of the bed 30 degrees and repositioning the rectal tube
- B. Placing the patient in a supine position and modifying the amount of solution
- C. Lowering the solution container and checking the temperature and flow rate
- D. Removing the rectal tube and notifying the primary care provider
Correct Answer: C
Rationale: Severe cramping during an enema suggests the solution is too cold or the flow rate is too fast. Lowering the container and checking temperature and flow rate (C) addresses this. Elevating the bed (A) or changing position (B) doesn't resolve cramping, and removing the tube (D) is premature.
You may also like to solve these questions
A nurse is planning a bowel program for a patient with frequent constipation after sustaining a spinal cord injury. What is the first step the nurse will take?
- A. Offering a diet that is low in residue
- B. Increasing fluid intake to 3,000 mL daily
- C. Administering daily enemas to stimulate peristalsis
- D. Assessing the patient's bowel patterns
Correct Answer: D
Rationale: The first step is assessing bowel patterns (D) to understand frequency, consistency, and triggers, following the nursing process. Diet (A), fluids (B), and enemas (C) are interventions based on assessment findings.
For a patient with which health problem or issue would a nurse expect the health care provider to order colostomy irrigation?
- A. IBS
- B. Left-sided end colostomy in the sigmoid colon
- C. Postradiation damage to the bowel
- D. Crohn disease
Correct Answer: B
Rationale: Colostomy irrigation is indicated for left-sided end colostomies in the sigmoid colon (B) to promote regular evacuation. IBS (A), postradiation damage (C), and Crohn disease (D) are contraindications due to bowel instability.
A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
- A. Administering a large volume of solution (500 to 1,000 mL)
- B. Mixing milk and molasses in equal parts for an enema
- C. Instructing the patient to retain the enema for at least 30 minutes
- D. Administering the enema while the patient is sitting on the toilet
Correct Answer: C
Rationale: Retention enemas require the patient to hold the solution for at least 30 minutes (C) to soften stool. Large volumes (A) are for cleansing enemas, milk and molasses (B) are for carminative enemas, and administering on the toilet (D) prevents retention.
A nurse caring for a patient who reports frequent constipation learns the patient uses phosphate and sodium citrate enemas several times weekly. What education would the nurse provide?
- A. Avoid consuming fiber or roughage in the diet.
- B. Sedentary activities will be helpful.
- C. These enemas should be avoided with kidney failure.
- D. Restrict your fluids to 1,000 mL daily.
Correct Answer: C
Rationale: Phosphate and sodium citrate enemas (C) are contraindicated in kidney failure due to risk of hyperphosphatemia. Fiber (A) promotes regularity, activity (B) aids peristalsis, and fluid restriction (D) worsens constipation.
A nurse is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
- A. Saline osmotic laxative
- B. Bulk-forming laxative
- C. Methylcellulose
- D. Stool softener
Correct Answer: A
Rationale: Saline osmotic laxatives (A) can cause fluid/electrolyte imbalances in older adults, especially with kidney or cardiac issues, and should be avoided. Bulk-forming (B, C) and stool softeners (D) are safer options.