ATI RN F U N D A M E N T A L
P R O C T O R E D EXAM
Q U E S T I O O N W ITH
A N S W E R S AND
R A T I O N A L E S NEW
U P DA TE 2026
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
P R O C T O R E D EXAM
Q U E S T I O O N W ITH
A N S W E R S AND
R A T I O N A L E S NEW
U P DA TE 2026
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
