ATI RN F U ND AM E NT AL
P R O C T O R E D EXAM
Q U E S T I O O N WITH
ANS W E R S AND
R A T I O N A L E S NEW
UPDATE 2026
A34nurse34is34preparing34to34administer34a34cleansing34enema34to34an34a
dult34client34in34preparation34for34a34diagnostic34procedure.34Which34o
f34the34following34are34appropriate34steps34for34the34nurse34to34take?34
Select34all.
A.34Warm3 4 the3 4 enema3 4 prior3 4 to3 4 instillation
B.Position3 4 the3 4 client3 4 on3 4 the3 4 left3 4 side3 4 w/the3 4 right3 4 leg3 4 flexed3 4 forward
C.Lubricate34the34rectal34tube34or34nozzle34D.
Slowly34insert34the34rectal34tube34about34234inc
hes
E.34Hang34the34enema34container342434inches34above34the
34client's34anus34A,34B,34C
Rational:34D34is34the34appropriate34length34of34insertion34for34a34
child,343-434for34an34adult.3424
inches34is34too34high34&34will34cause34it34to34run34to34fast34&
34possible34painful34distention34of34the34colon,341834inches
34is34the34recommended34height
While34a34nurse34is34administering34a34cleansing34enema,34the34client34repo
rts34abdominal34cramping.34Which34of34the34following34is34the34appropriat
e34intervention?
A.34Have34the34client34hold34his34breath34briefly
B.34Discontinue34the34fluid34instillation
C.Remind34the34client34that34cramping34is34common34at34this34time
D.Lower34the34enema34fluid34container
D.34Lower34the34enema34fluid34container
Rational:34This34will34slow34the34rate34of34instillation34&34relieve34so
me34discomfort
A34nurse34is34caring34for34a34client34who34has34been34sitting34in34a34c
hair34for34334hrs.34Which34of34the34following34problems34is34the34cli
ent34at34risk34for34developing?
,A.34Stasis34of34secretions
B.34Muscle34atrophy
, C.Pressure34ulcer3
4D.Fecal
impaction34Answe
r:34C
Rational:34Unrelieved34pressure34over34a34bony34prominence34for34t
oo34long34increases34the
risk34of34a34pressure34ulcer,34sitting34will34help34pr
event34stasis34of34secretions34B34and34D-
these34are34from34prolonged34bed34rest
l3
4
O
M
o
3
4
A
3
4
R
P R O C T O R E D EXAM
Q U E S T I O O N WITH
ANS W E R S AND
R A T I O N A L E S NEW
UPDATE 2026
A34nurse34is34preparing34to34administer34a34cleansing34enema34to34an34a
dult34client34in34preparation34for34a34diagnostic34procedure.34Which34o
f34the34following34are34appropriate34steps34for34the34nurse34to34take?34
Select34all.
A.34Warm3 4 the3 4 enema3 4 prior3 4 to3 4 instillation
B.Position3 4 the3 4 client3 4 on3 4 the3 4 left3 4 side3 4 w/the3 4 right3 4 leg3 4 flexed3 4 forward
C.Lubricate34the34rectal34tube34or34nozzle34D.
Slowly34insert34the34rectal34tube34about34234inc
hes
E.34Hang34the34enema34container342434inches34above34the
34client's34anus34A,34B,34C
Rational:34D34is34the34appropriate34length34of34insertion34for34a34
child,343-434for34an34adult.3424
inches34is34too34high34&34will34cause34it34to34run34to34fast34&
34possible34painful34distention34of34the34colon,341834inches
34is34the34recommended34height
While34a34nurse34is34administering34a34cleansing34enema,34the34client34repo
rts34abdominal34cramping.34Which34of34the34following34is34the34appropriat
e34intervention?
A.34Have34the34client34hold34his34breath34briefly
B.34Discontinue34the34fluid34instillation
C.Remind34the34client34that34cramping34is34common34at34this34time
D.Lower34the34enema34fluid34container
D.34Lower34the34enema34fluid34container
Rational:34This34will34slow34the34rate34of34instillation34&34relieve34so
me34discomfort
A34nurse34is34caring34for34a34client34who34has34been34sitting34in34a34c
hair34for34334hrs.34Which34of34the34following34problems34is34the34cli
ent34at34risk34for34developing?
,A.34Stasis34of34secretions
B.34Muscle34atrophy
, C.Pressure34ulcer3
4D.Fecal
impaction34Answe
r:34C
Rational:34Unrelieved34pressure34over34a34bony34prominence34for34t
oo34long34increases34the
risk34of34a34pressure34ulcer,34sitting34will34help34pr
event34stasis34of34secretions34B34and34D-
these34are34from34prolonged34bed34rest
l3
4
O
M
o
3
4
A
3
4
R
