ATI - Bowel Elimination

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? - Answer- 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. While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following actions should the nurse take? - Answer- 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. 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? - Answer- 7.5 cm to 10 cm (3 to 4 in). This is the appropriate length of insertion for an adult client. 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? - Answer- return-flow Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention. 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? - Answer- 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? - Answer- At least 30 min.