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
A65nurse65is65preparing65to65administer65a65cleansing65enema65to65an65a
dult65client65in65preparation65for65a65diagnostic65procedure.65Which65o
f65the65following65are65appropriate65steps65for65the65nurse65to65take?65
Select65all.
A.65Warm6 5 the6 5 enema6 5 prior6 5 to6 5 instillation
B.Position6 5 the6 5 client6 5 on6 5 the6 5 left6 5 side6 5 w/the6 5 right6 5 leg6 5 flexed6 5 forward
C.Lubricate65the65rectal65tube65or65nozzle65D.
Slowly65insert65the65rectal65tube65about65265inc
hes
E.65Hang65the65enema65container652465inches65above65the
65client's65anus65A,65B,65C
Rational:65D65is65the65appropriate65length65of65insertion65for65a65
child,653-465for65an65adult.6524
inches65is65too65high65&65will65cause65it65to65run65to65fast65&
65possible65painful65distention65of65the65colon,651865inches
65is65the65recommended65height
While65a65nurse65is65administering65a65cleansing65enema,65the65client65repo
rts65abdominal65cramping.65Which65of65the65following65is65the65appropriat
e65intervention?
A.65Have65the65client65hold65his65breath65briefly
B.65Discontinue65the65fluid65instillation
C.Remind65the65client65that65cramping65is65common65at65this65time
D.Lower65the65enema65fluid65container
D.65Lower65the65enema65fluid65container
Rational:65This65will65slow65the65rate65of65instillation65&65relieve65so
me65discomfort
A65nurse65is65caring65for65a65client65who65has65been65sitting65in65a65c
hair65for65365hrs.65Which65of65the65following65problems65is65the65cli
ent65at65risk65for65developing?
,A.65Stasis65of65secretions
B.65Muscle65atrophy
, C.Pressure65ulcer6
5D.Fecal
impaction65Answe
r:65C
Rational:65Unrelieved65pressure65over65a65bony65prominence65for65t
oo65long65increases65the
risk65of65a65pressure65ulcer,65sitting65will65help65pr
event65stasis65of65secretions65B65and65D-
these65are65from65prolonged65bed65rest
l6
5
O
M
o
6
5
A
6
5
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
A65nurse65is65preparing65to65administer65a65cleansing65enema65to65an65a
dult65client65in65preparation65for65a65diagnostic65procedure.65Which65o
f65the65following65are65appropriate65steps65for65the65nurse65to65take?65
Select65all.
A.65Warm6 5 the6 5 enema6 5 prior6 5 to6 5 instillation
B.Position6 5 the6 5 client6 5 on6 5 the6 5 left6 5 side6 5 w/the6 5 right6 5 leg6 5 flexed6 5 forward
C.Lubricate65the65rectal65tube65or65nozzle65D.
Slowly65insert65the65rectal65tube65about65265inc
hes
E.65Hang65the65enema65container652465inches65above65the
65client's65anus65A,65B,65C
Rational:65D65is65the65appropriate65length65of65insertion65for65a65
child,653-465for65an65adult.6524
inches65is65too65high65&65will65cause65it65to65run65to65fast65&
65possible65painful65distention65of65the65colon,651865inches
65is65the65recommended65height
While65a65nurse65is65administering65a65cleansing65enema,65the65client65repo
rts65abdominal65cramping.65Which65of65the65following65is65the65appropriat
e65intervention?
A.65Have65the65client65hold65his65breath65briefly
B.65Discontinue65the65fluid65instillation
C.Remind65the65client65that65cramping65is65common65at65this65time
D.Lower65the65enema65fluid65container
D.65Lower65the65enema65fluid65container
Rational:65This65will65slow65the65rate65of65instillation65&65relieve65so
me65discomfort
A65nurse65is65caring65for65a65client65who65has65been65sitting65in65a65c
hair65for65365hrs.65Which65of65the65following65problems65is65the65cli
ent65at65risk65for65developing?
,A.65Stasis65of65secretions
B.65Muscle65atrophy
, C.Pressure65ulcer6
5D.Fecal
impaction65Answe
r:65C
Rational:65Unrelieved65pressure65over65a65bony65prominence65for65t
oo65long65increases65the
risk65of65a65pressure65ulcer,65sitting65will65help65pr
event65stasis65of65secretions65B65and65D-
these65are65from65prolonged65bed65rest
l6
5
O
M
o
6
5
A
6
5
R
