ATI Skills Module - Enemas Flashcards


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1

A nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure?

Prepare 1,500 mL of enema fluid.Use tap water as the enema fluid.Hang the enema container 24 inches above the anus.Warm the enema solution prior to instillation.

Warm the enema solution prior the installation.

It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa.

2

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?

Dorsal recumbentProneRight lateral with both knees at chestLeft lateral with the right leg flexed

Left lateral with the right leg flexed.

This position makes it easier for the enemaa solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.

3

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient?

Instill 200 mL of fluid at 15-min intervals times four.Administer an antidiarrheal medication 3 hr prior to the enema.Administer the enema while the patient sits on the toilet.Place the patient in the dorsal recumbent position on a bedpan.

Place the patient in the dorsal recumbent position on a bedpan.

A patient who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the patient over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid likely to be expelled promptly and thus help maintain the patient's dignity.

4

A nurse is preparing to adminster an oil-retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for

at least 30 min, but preferably as long as he can.until the next time he feels the urge to defecate.as long as it takes to complete the procedure.about 10 to 15 min.

at least 30 min. but preferably as long as he can.

The enema will be most effective in softening the stool and lubricating its passageway if the patient retains the oil for as long as he can - 1 to 3 hr if possible. It takes between 30 min and 3hr for the oil to exert its therapeutic effect.

5

A nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

Measure the patient's vital signs.Stop the enema instillation.Notify the primary care provider.Lower the enema fluid container.

Lower the enema fluid container.

Some abdominal cramping is to be expected during enema administration. To ease the patient's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

6

A nurse who is administering a return-flow enema to a patient should instill 100mL of enema fluid then

wait 5 min and instill another 100 mL of fluid.help the patient to the toilet or bedside commode.instruct the patient to retain the fluid.lower the container to allow the solution to flow back out.

lower the container to allow the solution to flow back out

7

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

CleansingReturn-flowOil-retentionMedicated

Return-flow

These are used to expel flatus, stimulate peristalsis, and relieve abdominal distension.

8

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube

2.5 cm to 3.75 cm (1 to 1.5 in).5 cm to 7.5 cm (2 to 3 in).7.5 cm to 10 cm (3 to 4 in).10 cm to 12.5 cm (4 to 5 in).

7.5cm to 10cm (3 to 4in.)

this is the appropriate length of insertion for an adult patient.