ATI RN
FUNDAMENTAL
PROCTORED
E XA M
QUESTIOON
WIT H
ANSWERS
AND
RATIONALES
NEW
UPDATE 2 023 (1 0 0%
A C C URAT E!)
A nurse is preparing to administer a cleansing enema to an
adult client in preparation for a diagnostic procedure. Which
of the following are appropriate steps for the nurse to take?
Select all.
A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C.Lubricate the rectal tube or nozzle
D.Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches
above the client's anus A, B, C
Rational: D is the appropriate length of insertion for a
child, 3-4 for an adult. 24
inches is too high & will cause it to run to fast &
possible painful distention of the colon, 18 inches
is the recommended height
While a nurse is administering a cleansing enema, the client
reports abdominal cramping. Which of the following is the
appropriate intervention?
A. Have the client hold his breath briefly
B. Discontinue the fluid instillation
C.Remind the client that cramping is common at this time
D.Lower the enema fluid container
D. Lower the enema fluid container
,Rational: This will slow the rate of instillation &
relieve some discomfort
A nurse is caring for a client who has been sitting in a
chair for 3 hrs. Which of the following problems is the
client at risk for developing?
A. Stasis of secretions
B. Muscle atrophy
, C.Pressure
ulcer D.Fecal
impaction
Answer: C
Rational: Unrelieved pressure over a bony prominence
for too long increases the
risk of a pressure ulcer, sitting will help
prevent stasis of secretions B and D-these
are from prolonged bed rest
l
O
M
o
A
R
FUNDAMENTAL
PROCTORED
E XA M
QUESTIOON
WIT H
ANSWERS
AND
RATIONALES
NEW
UPDATE 2 023 (1 0 0%
A C C URAT E!)
A nurse is preparing to administer a cleansing enema to an
adult client in preparation for a diagnostic procedure. Which
of the following are appropriate steps for the nurse to take?
Select all.
A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C.Lubricate the rectal tube or nozzle
D.Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches
above the client's anus A, B, C
Rational: D is the appropriate length of insertion for a
child, 3-4 for an adult. 24
inches is too high & will cause it to run to fast &
possible painful distention of the colon, 18 inches
is the recommended height
While a nurse is administering a cleansing enema, the client
reports abdominal cramping. Which of the following is the
appropriate intervention?
A. Have the client hold his breath briefly
B. Discontinue the fluid instillation
C.Remind the client that cramping is common at this time
D.Lower the enema fluid container
D. Lower the enema fluid container
,Rational: This will slow the rate of instillation &
relieve some discomfort
A nurse is caring for a client who has been sitting in a
chair for 3 hrs. Which of the following problems is the
client at risk for developing?
A. Stasis of secretions
B. Muscle atrophy
, C.Pressure
ulcer D.Fecal
impaction
Answer: C
Rational: Unrelieved pressure over a bony prominence
for too long increases the
risk of a pressure ulcer, sitting will help
prevent stasis of secretions B and D-these
are from prolonged bed rest
l
O
M
o
A
R
