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Questions and Answers
A nurse is preparing to insert a rectal tube for a client experiencing flatulence. Which of the following actions is most crucial to perform before initiating the procedure?
A nurse is preparing to insert a rectal tube for a client experiencing flatulence. Which of the following actions is most crucial to perform before initiating the procedure?
- Administering a pain assessment to determine the client's level of discomfort
- Confirming the medical order for the rectal tube insertion (correct)
- Educating the client about dietary modifications to reduce gas formation
- Reviewing the client's medication list for drugs that may affect bowel motility
When inserting a rectal tube, what is the primary rationale for lubricating the tip of the tube generously?
When inserting a rectal tube, what is the primary rationale for lubricating the tip of the tube generously?
- To stimulate peristalsis and promote the expulsion of flatus
- To prevent the tube from adhering to the rectal mucosa
- To minimize patient discomfort and facilitate smooth insertion (correct)
- To reduce the risk of infection by creating a barrier against bacteria
After inserting a rectal tube, a nurse is preparing to secure it to the client's buttocks. Which of the following methods is most appropriate for securing the tube?
After inserting a rectal tube, a nurse is preparing to secure it to the client's buttocks. Which of the following methods is most appropriate for securing the tube?
- Using a sterile suture to secure the tube to the skin, ensuring stability
- Using adhesive tape to tightly secure the tube, ensuring it remains in place
- Applying a small amount of petroleum jelly around the insertion site to act as an adhesive
- Taping the tube loosely to allow for some movement and prevent pressure sores (correct)
Following the insertion of a rectal tube, the nurse observes a small amount of fecal drainage around the insertion site. What is the most appropriate initial nursing intervention?
Following the insertion of a rectal tube, the nurse observes a small amount of fecal drainage around the insertion site. What is the most appropriate initial nursing intervention?
A nurse is preparing to administer a rectal suppository to a client with constipation. What is the most important instruction to provide to the client regarding breathing during insertion?
A nurse is preparing to administer a rectal suppository to a client with constipation. What is the most important instruction to provide to the client regarding breathing during insertion?
After inserting a rectal suppository, the nurse instructs the client to retain the suppository for at least 15 minutes. Which of the following rationales best explains this instruction?
After inserting a rectal suppository, the nurse instructs the client to retain the suppository for at least 15 minutes. Which of the following rationales best explains this instruction?
While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take first?
While administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take first?
A nurse is preparing a cleansing enema for an adult client. How far should the nurse insert the enema tube into the rectum?
A nurse is preparing a cleansing enema for an adult client. How far should the nurse insert the enema tube into the rectum?
While administering a cleansing enema, the nurse observes that the client begins to exhibit signs of vagal nerve stimulation, such as bradycardia and diaphoresis. What is the most appropriate initial nursing intervention?
While administering a cleansing enema, the nurse observes that the client begins to exhibit signs of vagal nerve stimulation, such as bradycardia and diaphoresis. What is the most appropriate initial nursing intervention?
A nurse is providing instructions to a client who will be self-administering cleansing enemas at home. What is the most important safety instruction to emphasize?
A nurse is providing instructions to a client who will be self-administering cleansing enemas at home. What is the most important safety instruction to emphasize?
A nurse is planning to change an ostomy appliance for a client. Which of the following actions is most important to perform before removing the old appliance?
A nurse is planning to change an ostomy appliance for a client. Which of the following actions is most important to perform before removing the old appliance?
When changing an ostomy appliance, what is the primary rationale for measuring the stoma before cutting the opening in the new appliance?
When changing an ostomy appliance, what is the primary rationale for measuring the stoma before cutting the opening in the new appliance?
The nurse is teaching a client how to change their ostomy appliance at home. Which of the following instructions regarding peristomal skin care is most important?
The nurse is teaching a client how to change their ostomy appliance at home. Which of the following instructions regarding peristomal skin care is most important?
After applying a new ostomy appliance the nurse assesses the skin. Which of the following findings requires immediate intervention?
After applying a new ostomy appliance the nurse assesses the skin. Which of the following findings requires immediate intervention?
A nurse is preparing to irrigate a client's colostomy. Which of the following actions is most important to perform before initiating the procedure?
A nurse is preparing to irrigate a client's colostomy. Which of the following actions is most important to perform before initiating the procedure?
During colostomy irrigation, the client reports abdominal cramping. Which of the following actions should the nurse take first?
During colostomy irrigation, the client reports abdominal cramping. Which of the following actions should the nurse take first?
After the colostomy irrigation is complete, the nurse instructs the client to clamp the tubing and wait for a specified period before removing the sleeve. Which of the following rationales best explains this instruction?
After the colostomy irrigation is complete, the nurse instructs the client to clamp the tubing and wait for a specified period before removing the sleeve. Which of the following rationales best explains this instruction?
Following colostomy irrigation, a nurse teaches a client about proper stoma care. Which statement indicates a need for further teaching?
Following colostomy irrigation, a nurse teaches a client about proper stoma care. Which statement indicates a need for further teaching?
A nurse is caring for a client who requires a rectal tube to manage persistent flatulence. The client reports discomfort and a feeling of fullness even with the tube in place. Which intervention should the nurse implement first?
A nurse is caring for a client who requires a rectal tube to manage persistent flatulence. The client reports discomfort and a feeling of fullness even with the tube in place. Which intervention should the nurse implement first?
A nurse is about to insert a rectal suppository, and the client expresses anxiety about potential discomfort. What is the most appropriate action by the nurse?
A nurse is about to insert a rectal suppository, and the client expresses anxiety about potential discomfort. What is the most appropriate action by the nurse?
When administering a cleansing enema, the nurse notes resistance during insertion of the enema tube. What is the appropriate nursing action?
When administering a cleansing enema, the nurse notes resistance during insertion of the enema tube. What is the appropriate nursing action?
A client with a new colostomy reports feelings of self-consciousness and anxiety about changing the ostomy appliance. Which is the best initial nursing intervention?
A client with a new colostomy reports feelings of self-consciousness and anxiety about changing the ostomy appliance. Which is the best initial nursing intervention?
The health care provider orders an enema to prepare the client for a colonoscopy. What kind of enema should the nurse plan to administer?
The health care provider orders an enema to prepare the client for a colonoscopy. What kind of enema should the nurse plan to administer?
The nurse is caring for a client with frequent constipation. Which of the following interventions should the nurse implement to help treat the client's constipation?
The nurse is caring for a client with frequent constipation. Which of the following interventions should the nurse implement to help treat the client's constipation?
The nurse irrigates a client's colostomy, and the client suddenly begins to complain of severe cramping. What action should the nurse take first?
The nurse irrigates a client's colostomy, and the client suddenly begins to complain of severe cramping. What action should the nurse take first?
Which action should the nurse take to administer a rectal suppository to the client?
Which action should the nurse take to administer a rectal suppository to the client?
The nurse is preparing to administer an enema to an adult client to promote bowel elimination. How far should the nurse insert the tip of the enema tubing into the client's rectum?
The nurse is preparing to administer an enema to an adult client to promote bowel elimination. How far should the nurse insert the tip of the enema tubing into the client's rectum?
The nurse is preparing to insert a rectal tube for a client with excessive flatulence. Which position should the nurse assist the client into for insertion of the rectal tube?
The nurse is preparing to insert a rectal tube for a client with excessive flatulence. Which position should the nurse assist the client into for insertion of the rectal tube?
The nurse is planning care for a client with a colostomy. Which action should the nurse include in the plan to promote the integrity of the skin around the stoma?
The nurse is planning care for a client with a colostomy. Which action should the nurse include in the plan to promote the integrity of the skin around the stoma?
The nurse is performing a colostomy irrigation on a client and notes that the client is complaining of abdominal cramps. What action should the nurse take?
The nurse is performing a colostomy irrigation on a client and notes that the client is complaining of abdominal cramps. What action should the nurse take?
The nurse is preparing to administer an enema to a client with fecal impaction. Which type of enema should the nurse anticipate will be ordered by the health care provider?
The nurse is preparing to administer an enema to a client with fecal impaction. Which type of enema should the nurse anticipate will be ordered by the health care provider?
A nurse is caring for a client after a colostomy placement. Which of the following characteristics should the nurse expect to find when assessing a healthy stoma?
A nurse is caring for a client after a colostomy placement. Which of the following characteristics should the nurse expect to find when assessing a healthy stoma?
The nurse is developing a plan of care that lists interventions for assisting a client who has constipation secondary to opioid use. Which intervention is most appropriate for the nurse to include in the plan?
The nurse is developing a plan of care that lists interventions for assisting a client who has constipation secondary to opioid use. Which intervention is most appropriate for the nurse to include in the plan?
The nurse is administering an enema to a client. During administration, the client reports severe abdominal cramping and discomfort. What action should the nurse take initially?
The nurse is administering an enema to a client. During administration, the client reports severe abdominal cramping and discomfort. What action should the nurse take initially?
The nurse works on a surgical unit. The client returns from surgery with a new colostomy. Which action should the nurse perform first?
The nurse works on a surgical unit. The client returns from surgery with a new colostomy. Which action should the nurse perform first?
The nurse is providing discharge instructions to a client who reports frequent constipation. Which statement by the client indicates a need for further clarification?
The nurse is providing discharge instructions to a client who reports frequent constipation. Which statement by the client indicates a need for further clarification?
A nurse is caring for a client who has a prescription for a cleansing enema. When administering the enema, the client states they are experiencing abdominal cramping. Which of the following actions should the nurse take?
A nurse is caring for a client who has a prescription for a cleansing enema. When administering the enema, the client states they are experiencing abdominal cramping. Which of the following actions should the nurse take?
A nurse is teaching a client about the purpose of a return-flow enema. Which of the following reasons for this type of enema should the nurse include in the instructions?
A nurse is teaching a client about the purpose of a return-flow enema. Which of the following reasons for this type of enema should the nurse include in the instructions?
A nurse is preparing to administer a cleansing enema to an adult client. Which of the following steps should the nurse take?
A nurse is preparing to administer a cleansing enema to an adult client. Which of the following steps should the nurse take?
Flashcards
Rectal Tube Insertion
Rectal Tube Insertion
A procedure that uses a tube to relieve intestinal gas.
Sims Position
Sims Position
Positioning the client on their left side with the right knee and thigh flexed.
Rectal Suppository Insertion
Rectal Suppository Insertion
Introduce tapered end first, beyond the internal sphincter.
Cleansing Enema
Cleansing Enema
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Enema Positioning
Enema Positioning
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Enema Discomfort
Enema Discomfort
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Changing an Ostomy Appliance
Changing an Ostomy Appliance
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Irrigating a Colostomy
Irrigating a Colostomy
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Study Notes
- Inserting a Rectal Tube (Skill 31-1)
Assessment
- Check medical orders to ensure collaboration between nursing and medical teams.
- Use two methods to identify the client to support safety principles.
- Inspect the abdomen and palpate gently for distention; auscultate bowel sounds for baseline data.
- Determine the client's understanding of the procedure for health teaching.
Planning
- Obtain a 22- to 32-F catheter and lubricant for proper size and easy insertion.
Implementation
- Wash hands/use hand rub and wear gloves to prevent microorganism transmission.
- Pull privacy curtain to show respect for client's dignity
- Place the client in Sims position to facilitate access to the rectum.
- Lubricate the tip of the tube generously to ease insertion.
- Separate the buttocks to visualize the insertion location.
- Insert the tube 4-6 inches (10-15 cm) in adults to stimulate peristalsis and prevent tube displacement.
- Enclose the free end in a soft cloth or pad to absorb stool drainage.
- Tape the tube to the buttocks or inner thigh to allow movement without tube displacement.
- Leave the rectal tube for no more than 20 minutes to reduce the risk of impairing the sphincter.
- Reinsert every 3-4 hours if discomfort returns to reinstate therapeutic management.
Evaluation
- Assess for elimination of intestinal gas.
- Ask the client if symptoms are relieved.
- Check if the client reports any ill effects.
Documentation
- Record assessment data and intervention.
- Note the length of time the tube was in place.
- Document the client's response to the procedure.
- Inserting a Rectal Suppository (Skill 31-2)
Assessment
- Confirm medical orders to enable collaboration in treatment.
- Compare MAR with the written order for accuracy.
- Check the label on the suppository against the MAR three times to prevent errors.
- Use two client identifiers to ensure correct patient.
- Determine the client's understanding of the suppository's purpose for health teaching
Planning
- Administer suppository at the prescribed time according to the medical order.
- Obtain clean gloves and lubricant to facilitate insertion.
Implementation
- Wash hands/use hand rub to reduce microorganism transmission.
- Read the name on the client's ID band to prevent errors.
- Pull the privacy curtain for client modesty.
- Position the client in Sims' position to facilitate access.
- Drape the client to expose only the buttocks to ensure modesty
- Put on gloves to comply with standard precautions.
- Lubricate the suppository and index finger to reduce friction.
- Separate buttocks for visualization.
- Instruct client to take slow, deep breaths to promote relaxation.
- Insert tapered end of suppository beyond the internal anal sphincter to reach the optimal location.
- Avoid placing the suppository within stool to ensure effectiveness
Action
- Wipe excess lubricant for comfort.
- Instruct the client to retain the suppository for at least 15 minutes to enhance effectiveness.
- Advise contracting the gluteal muscles if there is an urge to avoid premature expulsion of the suppository.
- Ask the client to delay flushing the toilet for stool inspection to evaluate drug effectiveness.
- Remove gloves and wash hands to reduce microorganism transmission.
Evaluation
- Check if the client retains the suppository for 15 minutes.
- Evaluate if bowel elimination occurs.
Documentation
- Record drug, dose, route, and time.
- Note the outcome of drug administration.
- Administering a Cleansing Enema (Skill 31-3)
Assessment
- Check medical orders for the type of enema and prescribed solution to ensure correct treatment.
- Check the date of the client's last bowel movement to determine the need for impaction check.
- Identify the client using two methods to ensure correct patient.
- Wash hands/use hand rub to reduce transmission.
- Auscultate bowel sounds to establish status.
- Determine the client's understanding of the procedure to provide health teaching.
Planning
- Plan the location for enema solution and stool expulsion.
- Organize equipment including an enema set, solution, absorbent pad, lubricant, bath blanket, and gloves for efficient time management.
- Implement the procedure when specified or most appropriate to collaborate patient and doctor decisions.
- Prepare solution and equipment to provide access to supplies
Implementation
- Warm solution to 105°-110°F (40°-43°C) for comfort.
- Clamp tubing to prevent fluid loss.
- Fill the container with the specified solution to enable bowel cleansing.
- Pull the privacy curtain to demostrate respect for patient dignity.
- Position client in Sims to allow access to umbilicus.
- Drape to expose only buttocks and place waterproof pad to maintain modesty and protect bedding.
- Place(or hang) solution container above the level of the client's anus for facilitated gravity flow.
- Open the clamp, fill tubing with solution, and reclamp to purge air.
- Lubricate the tip of the tube to ease insertion.
- Separate buttocks to visualize insertion.
- Insert the tube 3-4 inches (7-10 cm) in adults.
- Direct the tubing at an angle pointing toward the umbilicus.
- Hold the tube in place to avoid displacement.
Action
- Release the clamp to instill the solution to fill the rectum.
- Briefly clamp the tube if cramping occurs, while instructing client to take deep breaths and contract sphincters to avoid further stimulation.
- Resume when cramping stops to facilitate effectiveness.
- Clamp and remove tubing once enema is done, or client can't retain fluid to complete procedure.
- Encourage client to retain solution to promote effectiveness.
- Hold the tube and pull a glove over to prevent direct contact.
- Remove used gloves/equipment to follow principles of medical asepsis
- Assist client to sit to aid defecation.
- Check expelled solution and provide data for effectiveness.
- Clean and dry client to show concern for the client's well-being.
Evaluation
- Check for sufficient solution amount instilled.
- Assess the expelled solution's amount.
- Confirm stool elimination.
Documentation
- Include the type of enema solution.
- Volume instilled.
- Document the procedure's outcome.
- Changing an Ostomy Appliance (Skill 31-4)
Assessment
- Wash hands/use hand rub for reduced transmission, complies with standard precautions.
- Identify client using two methods to support established safety principles,
- Assess the faceplate, pouch, and the peristomal skin to determine necessity and stoma condition.
- Find out how much the patient knows about stoma care, and prepare for self-care learning.
Planning
- Get replacement supplies and solutions for removing adhesives to facilitate organization.
- Plan for immediate replacement if localized symptoms prevents complications.
- Plan for asymptomatic client appliance change prior to meal as it coincides with gastrocolic less active reflex
- Plan to empty the pouch; this should take place before it's changed to prevent soiling.
Implementation
- Pull the privacy curtain to respect the client.
- Have patient in a supine/dorsal recumbent position for access.
- Wash hands/use hand rub, put on gloves for reduced transmission and compliance to standard precautions.
- Unfasten and discard into a water-proof receptacle to facilitate access.
- Gently peel the faceplate to avoid skin trauma.
- Cleanse mucus from skin with water/mild soap using a soft cloth, as well as suggest a bath/shower.
- Pat dry peristomal skin for adhesion of faceplate.
- Measure the stoma with the stomal guide to find the size.
- Trim to fit and avoid pressure, to avoid circulation impairment.
- Attach ring of faceplate and push into place to avoid faceplate having been applied.
- Fold/clamp the bottom pouch for sealing so leaking can be avoided.
- Peel backing adhensive to prepare.
Action
- Have client stand, or lie flat for a taut skin, wrinkles avoided.
- Postion opening on stoma and press outward to prevent air gaps
- Perform hand hygiene.
Evaluation
- The stoma appears moist and pink.
- The skin is dry, intact, no reddness, irritation.
- The new appliance adheres to the skin without wrinkles
Documentation
- Note assessment/peristomal skin/new appliance
Irrigating a Colostomy (Skill 31-5)
Assessment
- Check medical orders to verify type of irrigation and solutions.
- Identify the client with two methods.
- Determine the amount the client knows about colostomy and what degree.
Planning
- Obtain supplies and bedpan (if needed) to promote organization
- Prepare irrigation similar to enema to start mechanism
- Unclamp tubing
Implementation
- Assist the patient into sitting postion for drainage
- Place absorbent pads for spillage
- Hang container 12 inches above stoma and follow standard precautions
- Empty the pouch and connect the sleeve.
Action
- Place the lower sleeve into toliet for collection.
- Lubricate cone at the end
- Open the irrigation sleeve.
- Insert into stoma
- Hold cone and release clamp.
- Prevent expulsion of cone by tubing and bowel adjustments.
- Wait if cramping occurs
- Remove cone, close sleeve to keep downward direction.
- Divert with activites.
- Clean and remove excessive material maintained and close tissue.
Evaluation
- Appliance and skin are looked at.
- Perform measures again to remove germs.
Documentation
- Type and volume.
- Note procedure
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