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Questions and Answers
A nurse is preparing to insert a rectal tube for a client experiencing flatulence. What is the MOST important assessment the nurse should perform before the procedure?
A nurse is preparing to insert a rectal tube for a client experiencing flatulence. What is the MOST important assessment the nurse should perform before the procedure?
- Assess the client's level of mobility.
- Evaluate the client's nutritional status.
- Determine the client's pain level.
- Check the client's medical orders. (correct)
When inserting a rectal tube for an adult client, how far should the nurse insert the tube?
When inserting a rectal tube for an adult client, how far should the nurse insert the tube?
- 4-6 inches (10-15 cm) (correct)
- 1-2 inches (2.5-5 cm)
- 8-10 inches (20-25 cm)
- 6-8 inches (15-20 cm)
A nurse is preparing to administer a rectal suppository to a client. Which position is MOST appropriate for the client during this procedure?
A nurse is preparing to administer a rectal suppository to a client. Which position is MOST appropriate for the client during this procedure?
- Supine position
- Prone position
- Fowler's position
- Sims position (correct)
A nurse has just inserted a rectal suppository. What instruction should the nurse give to the client?
A nurse has just inserted a rectal suppository. What instruction should the nurse give to the client?
When administering a cleansing enema, how far should the nurse insert the enema tube into the adult client's rectum?
When administering a cleansing enema, how far should the nurse insert the enema tube into the adult client's rectum?
A nurse is preparing to administer a cleansing enema. To what temperature should the nurse warm the enema solution?
A nurse is preparing to administer a cleansing enema. To what temperature should the nurse warm the enema solution?
During the administration of a cleansing enema, the client reports cramping. What is the appropriate nursing intervention?
During the administration of a cleansing enema, the client reports cramping. What is the appropriate nursing intervention?
A nurse is providing education to a client who will start self-administering a colostomy irrigation at home. The nurse should emphasize the importance of irrigating the colostomy at the same time each day to:
A nurse is providing education to a client who will start self-administering a colostomy irrigation at home. The nurse should emphasize the importance of irrigating the colostomy at the same time each day to:
What is the PRIMARY reason for lubricating the tip of a rectal tube before insertion?
What is the PRIMARY reason for lubricating the tip of a rectal tube before insertion?
A nurse is preparing to change an ostomy appliance. What should the nurse do FIRST?
A nurse is preparing to change an ostomy appliance. What should the nurse do FIRST?
A postoperative client has an order for the insertion of a rectal tube PRN for the relief of flatus. Before inserting the rectal tube, the nurse should:
A postoperative client has an order for the insertion of a rectal tube PRN for the relief of flatus. Before inserting the rectal tube, the nurse should:
A nurse is teaching a client how to administer a cleansing enema at home. Which instruction is MOST important for the nurse to include?
A nurse is teaching a client how to administer a cleansing enema at home. Which instruction is MOST important for the nurse to include?
A nurse is preparing to change a client’s ostomy appliance. The nurse notes that the skin around the stoma is excoriated. What is the MOST appropriate initial nursing intervention?
A nurse is preparing to change a client’s ostomy appliance. The nurse notes that the skin around the stoma is excoriated. What is the MOST appropriate initial nursing intervention?
A nurse is teaching a client with a colostomy how to perform an irrigation. The client reports experiencing abdominal cramps during the procedure. What should the nurse advise the client to do?
A nurse is teaching a client with a colostomy how to perform an irrigation. The client reports experiencing abdominal cramps during the procedure. What should the nurse advise the client to do?
A nurse has received an order to administer a cleansing enema to an adult client. Before initiating the enema, it is MOST important for the nurse to assess the client for?
A nurse has received an order to administer a cleansing enema to an adult client. Before initiating the enema, it is MOST important for the nurse to assess the client for?
After inserting a rectal tube, a nurse should leave it in place for no longer than:
After inserting a rectal tube, a nurse should leave it in place for no longer than:
Prior to the insertion of a rectal suppository, a nurse explains the procedure to a client. Which response by the client indicates a need for further teaching?
Prior to the insertion of a rectal suppository, a nurse explains the procedure to a client. Which response by the client indicates a need for further teaching?
When educating a client about the purpose of an enema, a nurse would include which of the following?
When educating a client about the purpose of an enema, a nurse would include which of the following?
A patient with a new colostomy asks why the stoma and peristomal skin need regular cleaning, how should the nurse respond?
A patient with a new colostomy asks why the stoma and peristomal skin need regular cleaning, how should the nurse respond?
When discussing colostomy irrigation with a patient, the nurse should emphasize?
When discussing colostomy irrigation with a patient, the nurse should emphasize?
Flashcards
Checking medical orders
Checking medical orders
Collaboration between nursing activities and the medical treatment plan.
Two client identifiers
Two client identifiers
Supports safety principles, ensuring correct patient gets the intervention.
Inspect abdomen & bowel sounds
Inspect abdomen & bowel sounds
Baseline data aids future problem assessment.
Client understanding assessment
Client understanding assessment
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Hand hygiene and gloves
Hand hygiene and gloves
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Pulling privacy curtain
Pulling privacy curtain
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Rectal tube insertion length
Rectal tube insertion length
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Enclosing the tube
Enclosing the tube
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Excess lubricant wiped away
Excess lubricant wiped away
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Inspect the stool after suppository
Inspect the stool after suppository
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Planning the enema location
Planning the enema location
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Warm enema solution
Warm enema solution
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Draping during enema
Draping during enema
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Height of the container
Height of the container
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Prime enema tubing
Prime enema tubing
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Enema insertion direction
Enema insertion direction
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Deep breathes & sphincter contractions
Deep breathes & sphincter contractions
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Assisting the client to sit
Assisting the client to sit
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Examine the expelled solution
Examine the expelled solution
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Peristomal skin assessment
Peristomal skin assessment
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Study Notes
Inserting a Rectal Tube
- Checking medical orders ensures collaboration between nursing activities and medical treatment.
- Client identification using two methods supports the principles of safety recommended by The Joint Commission.
- Abdominal inspection, bowel sounds auscultation, and gentle palpation provide baseline data for future comparisons.
- Assessing the client's understanding of the procedure offers an opportunity for health teaching.
- A 22- to 32-F catheter and lubricant are required for proper size and easy insertion.
- Hand hygiene and glove use reduce the transmission of microorganisms.
- Pulling the privacy curtain demonstrates respect for the client's dignity.
- Placing the client in a Sims position facilitates access to the rectum.
- Generous lubrication of the tube eases insertion.
- Separating the buttocks helps visualize the insertion location.
- Inserting the tube 4-6 inches in an adult places the distal tip above the sphincter muscles, stimulates peristalsis, and prevents tube displacement.
- Enclosing the free end of the tube within a clean cloth provides a means for absorbing stool drainage.
- Taping the tube to the buttocks or inner thigh allows the client to ambulate without tube displacement.
- Leaving the rectal tube in place for no longer than 20 minutes reduces the risk of impairing the sphincter.
- Reinserting the tube every 3-4 hours if discomfort returns reinstitutes therapeutic management.
- Evaluation includes assessing for eliminated intestinal gas, relieved symptoms, and absence of ill effects.
- Documentation should include assessment data, the intervention, the length of time the tube was in place, and the client's response.
Inserting a Rectal Suppository
- Checking the medical orders for the suppository ensures collaboration between nursing activities and the prescribed medical treatment.
- Comparing the medication administration record (MAR) with the written medical order ensures accuracy.
- Reading and comparing the medication label with the MAR at least three times prevents errors.
- Using two methods to identify the client supports the principles of safety recommended by The Joint Commission.
- Determining the client's understanding of the purpose and technique of suppository administration provides an opportunity for health teaching.
- Preparing to administer the suppository according to the prescribed time complies with medical orders.
- Obtaining clean gloves and lubricant facilitates insertion.
- Washing hands or using an alcohol-based hand rub reduces the transmission of microorganisms.
- Reading the client's identification band prevents errors.
- Pulling the privacy curtain demonstrates respect for the client's modesty and dignity.
- Placing the client in a Sims position facilitates access to the rectum.
- Draping the client to expose only the buttocks ensures modesty and dignity.
- Putting on gloves reduces the transmission of microorganisms and complies with standard precautions.
- Lubricating the suppository and index finger of the dominant hand reduces friction and tissue trauma.
- Separating the buttocks enhances visualization.
- Instructing the client to take slow, deep breaths promotes muscle relaxation and places the suppository in the best location for a local effect.
- Insertion of the suppository beyond the internal anal sphincter places the suppository in the best location for achieving a local effect.
- Avoiding placement of the suppository within stool reduces effectiveness.
- Wiping excess lubricant from around the anus with a paper tissue promotes comfort.
- Telling the client to retain the suppository for at least 15 minutes enhances effectiveness.
- Suggesting contraction of the gluteal muscles if there is a premature urge to expel the suppository tightens the anal sphincters.
- Asking the client to wait to flush the toilet until after the stool has been inspected provides an opportunity for evaluating the drug's effectiveness.
- Removing gloves and washing hands reduces the transmission of microorganisms.
- Evaluation includes whether the client retains the suppository for 15 minutes and bowel elimination occurs.
- Documentation should include drug, dose, route, and time, and the outcome of drug administration.
Administering a Cleansing Enema
- Checking the medical orders for the type of enema and prescribed solution ensures collaboration between nursing activities and medical treatment.
- Checking the date of the client's last bowel movement helps determine the need to check for an impaction.
- Using two methods to identify the client supports the principles of safety.
- Hand hygiene reduces the transmission of microorganisms.
- Auscultating bowel sounds establishes the status of peristalsis.
- Determining client understanding provides an opportunity for health teaching.
- Planning the location where the client will expel the enema solution and stool determines whether a bedpan is necessary.
- Obtaining the appropriate equipment facilitates organization and efficient time management.
- Planning to perform the procedure according to physician's order demonstrates collaboration and participation of the client.
- Preparing the solution and equipment provides access to supplies.
- Warming the solution to approximately 105°-110°F promotes comfort and safety.
- Clamping the tubing prevents the loss of fluid.
- Filling the container with the specified solution provides the mechanism for cleansing the bowel.
- Pulling the privacy curtain demonstrates respect for the client's dignity.
- Placing the client in a Sims position facilitates access to the rectum.
- Draping the client preserves modesty and protects bed linen.
- Putting on gloves reduces the transmission of microorganisms.
- Placing (or hanging) the solution container 12-20 inches above the client's anus facilitates gravity flow.
- Opening the clamp and filling the tubing purges air from the tubing.
- Lubricating the tip of the tube eases insertion.
- Separating the buttocks helps visualize insertion.
- Inserting the tube 3-4 inches in an adult places the distal tip above the sphincters.
- Directing the tubing toward the umbilicus follows the contour of the rectum.
- Holding the tube in place with one hand avoids displacement.
- Releasing the clamp promotes instillation and fills the rectum.
- Clamping the tube for a brief period and having the client take deep breaths if cramping occurs avoids further stimulation.
- Resuming instillation when cramping is relieved facilitates effectiveness.
- Clamping and removing the tubing after sufficient solution completes the procedure.
- Encouraging the client to retain the solution promotes effectiveness.
- Holding the enema tubing prevents direct contact.
- Removing and discarding the remaining glove follows the principles of medical asepsis.
- Assisting the client to sit while eliminating the solution and stool aids in defecation.
- Examining the expelled solution provides data for evaluating the effectiveness of the procedure.
- Cleaning and drying the client demonstrates concern for the client's well-being.
- Evaluation includes if a sufficient amount of solution is instilled and expelled, and if the client eliminates stool.
- Documentation includes the type of enema solution, volume instilled, and outcome of procedure.
Changing an Ostomy Appliance
- Washing hands or using an alcohol-based hand rub reduces the transmission of infection.
- Using two methods to identify the client supports safety principles.
- Inspecting the faceplate, pouch, and peristomal skin determines the necessity for changing the appliance.
- Determining the client's understanding provides an opportunity for teaching and assuming self-care.
- Obtaining replacement equipment and supplies facilitates management.
- Planning to replace the appliance immediately prevents complications.
- Scheduling an appliance change for an asymptomatic client coincides with a time when the gastrocolic reflex is less active.
- Planning to empty the pouch just before the appliance will be changed prevents soiling.
- Pulling the privacy curtain demonstrates respect for the client's dignity.
- Placing the client in a supine or dorsal recumbent position facilitates access to the stoma.
- Washing hands and applying gloves reduces transmission of microorganisms.
- Unfastening the pouch and discarding it in a waterproof container provides access to the faceplate.
- Gently peeling the faceplate from the skin prevents skin trauma.
- Washing the peristomal area cleans mucus and stool from the skin.
- Patting the peristomal skin dry promotes potential adhesion when the faceplate is applied.
- Measuring the stoma determines its size.
- Trimming the opening avoids pinching or pressure.
- Avoids pushing pouch into place after the faceplate is applied.
- Attach a new pouch to the ring of the faceplate.
- Seals the pouch so leaking will not occur.
- Have the client stand or lie flat for application.
- Position the stoma for positioning and press in place.
- Performing hand hygiene removes microorganisms.
Irrigating a Colostomy
- Checking the written order and type of solution ensures collaboration.
- Using two methods to identify the client supports safety.
- Determining how much they understand helps assume self care.
- Obtaining an irrigating bag with the proper tube and amount promotes organization and efficiency.
- Preparing the irrigating bag with the solution will ease irrigation.
- Removing air from the tubing removes air and instills the solution.
- Assisting to a sitting position in bed facilitates to collect and empty.
- Having the client hold the container facilitates gravity flow.
- Emptying and removing protects from microogranisms.
- Positioning the container in the proper placement ensures placement.
- Placing the lower end and using the irrigation bag on the end is easier.
- Lubricating the cone will ease insertion.
- Placing the cone will properly perform irrigation.
- Cleaning and drying is tissue intergrity.
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