Before administering an enema, the nurse should inspect the patient's abdomen for distention. This provides a baseline for determining the effectiveness of the enema. To plan for appropriate teaching measures, the nurse should determine the patient's level of understanding of the purpose of the enema. The nurse should review the health care provider's order for the type of enema and the amount to be given. Before administering an enema, the nurse should review the patient's medical record for increased intracranial pressure, glaucoma, or recent abdominal, rectal, or prostate surgery because these conditions contraindicate the use of enemas. - answer-While assessing a patient before administering an enema, the nurse inspects the patient's abdomen for distention. What is the purpose of this nursing intervention?
A. It allows the nurse to plan for appropriate teaching measures.
B. It helps determine the number and type of enemas to be given.
C. It helps determine conditions that contraindicate the use of enemas.
D. It provides a baseline for determining the effectiveness of the enema.
A
The nurse should not give an enema to a patient sitting on the toilet because the position of the rectal tubing could injure the rectal wall. When giving an enema to an immobilized patient, it is always recommended that the patient be positioned on a bedpan. The use of sterile technique is not necessary when administering an enema, because the colon already contains bacteria. However, the nurse should wear gloves to prevent the transmission of fecal microorganisms. It is appropriate to ask the patient to retain the enema solution for a specific length of time before defecation. - answer-A nurse is preparing to administer an enema to a patient who is scheduled for a colonoscopy. Which action taken by the nurse may lead to a complication?
A. Giving the enema with the patient sitting on the toilet
B. Giving the enema with the patient positioned on a bedpan
C. Refraining from sterile technique while administering the enema
D. Asking the patient to retain the enema solution for a specific length of time
B
Methylcellulose is a bulk-forming stool softener that absorbs water and increases solid intestinal bulk. It is a drug of choice for chronic constipation and is available in powder form. The nurse should instruct the patient to mix the powder with at least 250 mL of water or juice and swallow it quickly; if not, it could cause constipation. The nurse should advise patients that prescribed stimulant laxatives should only be taken occasionally to prevent dependence on the stimulus for defecation. Methylcellulose may cause the passage of stool 12 to 24 hours after taking the medication. Therefore, the patient need not report to the health care provider if he or she does not pass stool within 8 to 10 hours of taking the medication. Increased gas formation and flatus may occur when the patient first starts taking methylcellulose; this will subside after 4 or 5 days. Therefore, the nurse should not instruct the patient to - answer-The health care provider prescribes methylcellulose to a patient with chronic constipation. Which instruction provided by the nurse will help prevent complications?
A. "Do not use the medication on a regular basis."
C
Enemas that uses hypertonic solutions are low volume and are designed for patients who cannot tolerate a large volume of fluid. This type of enema is contraindicated in infants and dehydrated patients. A patient with a dangerously high serum potassium level may receive a medicated enema that contains sodium polystyrene sulfonate. - answer-To which patient will the nurse most likely give a hypertonic solution enema?
A. An infant who is unable to defecate
B. A dehydrated patient who has constipation
C. A patient who cannot tolerate a large volume of fluid
D. A patient with a dangerously high serum potassium level
C
To determine constipation, the nurse should ask the patient about feelings of having incomplete bowel movements. To determine indigestion, the nurse should ask the patient about a bloated fee
ati ati pharmacology comprehensive comprehensive predictor health care health care / nursing health care/ nursing healthcare hesi hesi rn exit maternal newborn med surg medical surgical mental health nurs nursing nursing & health nutrition pathophysiology pediatrics pharmacology psychology tci test bank tncc
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