Large volume enema cleansing- Quiz

Place in order the steps the nurse should take if a client reports cramping and bloating during enema administration. Use all options.

1)Stop administration if the client reports severe cramping and bloating. 2)Encourage the client to take short, panting breaths until the cramping subsides. 3)Administer the enema slowly at a height less than 18 in (0.5 m) above the client. 4)Discontinue the procedure and notify health care provider if pain occurs.

The nurse is administering a large-volume enema to treat a client's constipation. After checking the enema device for defects, what should the nurse do next?

Add the enema solution and any additives to the enema bag. After checking the enema device the nurse should add the enema solution and any prescribed additives to the enema bag. The next step is to release the clamp and allow fluid to progress through the tube to remove air, then reclamp. The nurse would then hang the bag on the IV pole. Lubricating the rectal tube and inserting it into the anus are steps that follow the preparation of the solution.

The nurse is administering a large-volume cleansing enema. After stopping the enema, which instructions should the nurse provide if the client reports severe pain and bloating?

Breathe out in short, panting breaths. If the client experiences severe pain and bloating during enema administration, the nurse should stop the enema and instruct the client to take short, panting breaths. This helps to relieve the pain and bloating sensation. Deep breathing helps relax the anal sphincter and facilitates insertion but holding it would not relieve pain and bloating. Short, shallow breaths will not relieve abdominal cramping and bloating sensation.

The nurse is caring for a client whose health care provider has written a prescription for "enemas until clear." Which explanation to the client about this procedure is correct?

"I will administer up to three enemas until there are no more pieces of stool in enema return." If the prescription states the enema is to be given "until clear," check with the health care provider before administering more than three enemas. Severe fluid and electrolyte imbalances may occur if the client receives more than three cleansing enemas. Results are considered clear whenever there are no more pieces of stool in enema return. The solution may be colored, but still considered a clear return. The client's ability to consume clear liquids without nausea would not exempt the client from receiving the enemas. A nurse would not be able to determine whether the entire intestinal tract is clear.

The nurse observes the unlicensed assistive personnel (UAP) administering a large-volume enema to an older adult client. Which action by the UAP would require the nurse to intervene?

Continuing administration while the client reports severe cramping and bloating.

A nurse is preparing to administer an enema to a client. Reviewing the health history, however, the nurse realizes that the client often has a problem with sodium retention. The nurse should know that it would be a contraindication to administer which type of enema to this client?

Hypertonic Small-volume enemas (adult: 70 to 130 mL) are also known as hypertonic enemas. These hypertonic solutions work by drawing water into the colon, which stimulates the defecation reflex. They may be contraindicated in clients for whom sodium retention is a problem. The other types of enemas listed should be fine to administer to this client.

The nurse is getting ready to administer a large-volume cleansing enema to a client undergoing bowel surgery. Which action should the nurse take prior to the procedure?

Lubricate the tip of the rectal tube for easy insertion. The nurse should warm the enema solution, lubricate the tip for easy insertion, and instruct the client to take several deep breaths during administration instead of bearing down. The solution should flow continuously rather than be administered intermittently.

A nurse needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?

Oil-retention Oil-retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. A hypertonic enema draws water into the colon, which stimulates the defecation reflex. Carminative enemas help to expel flatus from the rectum and relieve distention secondary to flatus. Anthelmintic enemas are administered to destroy intestinal parasites.

The nurse is reviewing a client's laboratory work before administering a large-volume enema. Which laboratory result indicates that a nurse should confer with the health care provider before administering the enema?

Platelet count of 18,000/mm3 A platelet count of less than 20,000/mm3 (20.00 ×109/L) may seriously compromise the client's ability to clot blood. Therefore, the nurse should not perform any unnecessary procedures that would place the client at risk for bleeding or infection, such as giving an enema. A serum albumin level of 3.1 g/dL (31 g/L) suggests malnutrition. An arterial pH level of 5.2 indicates alkalosis. A WBC count of 15,200/mm3 (15.20 × 109/L) suggests infection. Malnutrition, alkalosis, and infection would not contraindicate administering an enema.

Which clients have contraindications to receiving an enema? Select all that apply.

client with bowel obstruction, client who has just undergone colon surgery, client with severe abdominal pain, client with bowel inflammation The nurse should not administer enemas to clients who have severe abdominal pain, bowel obstruction, bowel inflammation or bowel infection, or after rectal, prostate, or colon surgery. Enemas are indicated for relieving fecal impaction and improving visualization of the intestinal tract by radiographic or instrument examination.

Which nursing assessment takes priority when administering an enema to a client?

dizziness When administering an enema to a client, the nurse would assess the client for cramping, dizziness, or pain. The enema may stimulate a vagal response, which increases parasympathetic stimulation. This causes a decrease in the heart rate. Headache and tachypnea are not usually associated with receiving an enema. Anxiety may occur, but dizziness and bradycardia take priority.

The nurse is inserting an enema tube into the anus of the client to treat constipation. How should the nurse insert the tube?

Insert tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval. The nurse would insert the enema tube 3 to 4 in (7.5 to 10 cm) and angle toward the naval. The anal canal is about 1 to 2 in (2.5 to 5 cm) long. The tube should be inserted past the external and internal sphincters, but further insertion may damage the intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus helps prevent perforation of the bowel. Inserting the tube 1 to 2 in (2.5 to 5 cm) is not far enough to pass the internal sphincter. Angling toward the bladder does not follow the normal intestinal contour and could cause perforation of the bowel.

The nurse is administering a large-volume cleansing enema to a client who reports severe cramping and bloating in the abdominal area. What is the recommended nursing intervention based on this report?

Stop the flow and encourage the client to take deep breaths before restarting the enema. If the client reports pain, cramping, or bloating, the nurse should stop the flow of the enema for a few minutes, encourage the client to take deep breaths and relax, and then start the flow again when the pain subsides. The nurse should stop the enema and notify the health care provider if the pain continues the second time. It is not necessary to contact the health care provider at this time. The nurse should not continue administering the enema until after the client has had a few minutes of deep breathing to relieve the cramping. The client can be told that this is a common occurrence, but the nurse should stop the enema for a few minutes and instruct the client to take deep breaths.

Which client situation would necessitate the nurse stopping the administration of an enema?MCW

reports of severe cramping If the client experiences severe cramping and bloating during enema administration, the nurse should stop the enema and instruct the client to take short, panting breaths. Anxiety might increase the client's heart rate, but it would be more of a concern if bradycardia occurred due to vagal stimulation. The nurse may want to encourage slow deep breaths to help the client relax, but elevated heart rate would not require stopping the enema. Constipation is going to be relieved by the enema and should not require the nurse to stop administration. The client may expel the enema and stool using a bedpan, therefore being on bedrest should not necessitate stopping the enema