ATI - Bowel Elimination

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube?

7.5 cm to 10 cm (3 to 4 in). This is the appropriate length of insertion for an adult client.

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 actions should the nurse take?

Warm the enema solution prior to instillation. 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.

A nurse who is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take?

Lower the container to allow the solution to flow back out. Return-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times.

A nurse is preparing to administer a cleansing enema to a patient who has poor sphincter control. Which of the following actions should the nurse take?

Place the patient in the dorsal recumbent position on a bedpan. A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled.

A nurse is preparing to administer an oil-retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations?

At least 30 min. The enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min.

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

Left lateral with the right leg flexed This position makes it easier for the enema 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.

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas?

return-flow Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following actions should the nurse take?

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