1. A nurse is preparing to administer a soapsuds enema to an adult client. After explaining the procedure and positioning the client, the nurse inserts the rectal tube into the client's rectum a maximal distance of how many inches?
A. 1½ inches (3.8 cm)
B. 3 inches (7.5 cm)
C. 4 inches (10 cm)
D. 6 inches (15 cm)
2. A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. What action would the nurse take?
A. Clamp the enema bag tubing.
B. Remove the enema tube and allow the client to rest.
C. Stop the instillation and allow the client to expel the solution.
D. Raise the enema bag to quickly finish instillation of the solution.
3. A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse would take which action?
Answer (2)
For the enema insertion, the correct depth is C. 4 inches (10 cm) . If the client experiences cramping during the enema, the nurse should stop the instillation and allow for expulsion. Lastly, while monitoring heart rate decreases during fecal removal, no immediate action is needed unless the client shows distress.
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For inserting the rectal tube during a soapsuds enema, the maximal distance for an adult client is typically 4 inches (10 cm) . When performing this procedure, it's important to ensure the insertion is gentle to avoid any harm to the rectal tissues. Therefore, the correct answer is C. 4 inches (10 cm).
If a client complains of abdominal cramping while the enema solution is being instilled, the nurse should clamp the enema bag tubing. This action helps to temporarily stop the flow of the solution, allowing the client to relax and alleviate discomfort. Once the cramping subsides, the nurse can proceed with the administration at a slower pace. Thus, the correct action is A. Clamp the enema bag tubing.
During the digital removal of feces, monitoring the client's heart rate is crucial due to the risk of stimulating the vagus nerve and causing a drop in heart rate. If the heart rate decreases from 88 beats per minute to 82 beats per minute, the nurse should be cautious and may consider stopping the procedure and allowing the client to rest further to avoid any adverse cardiovascular effects. It is important to ensure the client's safety and comfort during such procedures.
