Quiz: Administering a Large-Volume Cleansing Enema

the nursing 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?

" i will administer up to three enemas until there is no more pieces of stool in enema return"

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

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.

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.

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

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 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

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

client with severe abdominal pain, client who has just undergone colon surgery, client with bowel obstruction, client with bowel inflammation

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

dizziness

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

inseert tube 3 to 4in (7.5 to 10 cm) and angle toward the naval.

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

which client situation would neccessitate the nurse stopping the administartion of an enema?

reports of severe cramping