Stop the procedure and monitor client's heart rate. Show A vagal response occurs when the vagus nerve is simulated, causing parasympathetic stimulation, which triggers a decrease in heart rate, light-headedness, nausea, and dizziness. The best action is to stop the procedure and monitor the client's heart rate and blood pressure. If the heart rate and blood pressure remain low, then the nurse should contact the health care provider. However, contacting the health care provider is not the first action, because the nurse must stop the enema and assess pulse and blood pressure prior to contacting the health care provider. Because this is not a normal response, it is inappropriate to reassure the client that it is normal. Slowing the enema will still stimulate the vagal nerve, and this action does not relieve the problem. Recommended textbook solutions
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Terms in this set (5)Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? A. Assess for the presence of external hemorrhoids. B. Provide assistance to the bathroom for expulsion of fluid and stool. Rationale: Assisting an older adult to the bathroom helps ensure the patient's safety because it may prevent a fall. While a patient with hemorrhoids may require special care during insertion of the tip of the rectal tube, this intervention pertains to the patient's comfort, not to his or her safety. Documenting the patient's physical response to the enema is appropriate, but this action pertains to recording and reporting, not safety. Instructing the patient to attempt to retain the fluid for 2 to 5 minutes may help make the enema more effective, but will not make it safer. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. Rationale: Lubricating the first 6.5 to 7.5 cm facilitates insertion of the rectal tube. Placing the patient in a side-lying position with the right knee flexed aids in retention of the solution. It does not facilitate insertion of the rectal tube. Flushing the tubing with solution will not facilitate insertion of the rectal tube. Holding the tube in the rectum until all of the fluid has been instilled helps minimize the possibility of expelling the rectal tube. It does not, however, facilitate insertion of the tube. The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, "Enemas until clear." Which statement made by NAP requires the nurse to follow-up? A. "I'll need help to turn her onto her side." B. "It may take three or four enemas to achieve a clear return." Rationale: Stating it may take three or four enemas to achieve a clear return requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas. This requires no follow-up, since more than one person may be required to turn a patient onto her side. Testing the water temperature on the wrist is appropriate, so this statement requires no follow-up. Stating that the enema will wear her out reflects appropriate concern for the patient and requires no follow-up. The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? A. "I'll warm up the solution before instilling it." D. "I'll instill the solution and then check in on my other patients until I get the call signal." Rationale: After instilling the solution, NAP should remain with the patient until he or she is ready to defecate, this statement requires follow-up. Warming the solution is appropriate. The patient is placed in a left side-lying position to allow the solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. A waterproof pad may be placed under the patient if necessary. Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? A. Lubricate the
tip of the rectal tube. C. Perform hand hygiene before donning gloves. Rationale: Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff. While lubricating the tip of the rectal tube is appropriate, it pertains to instillation of the enema, not to reducing the risk of infection. Padding the patient's bed thoroughly is appropriate; it pertains to the patient's comfort, not to reducing the risk of infection. While helping the patient onto a bedpan is appropriate, it pertains to the procedure itself, not to reducing the risk of infection. Students also viewedUrinary Catheterization: 210L Quiz #1125 terms DarbyCooksey Managing a Nasogastric Tube5 terms kaylingroce NUR 313: Providing Enteral Feeding5 terms Kaytlanl Fecal Occult Blood Testing5 terms jaymi_lyn_catalfano Sets found in the same folderFndmntls Fnl 50150 terms yanjuji NDNIQI Pressure Injury Training Case Study Scenari…16 terms angelakantor_ ATI Fundamentals 1 Quiz40 terms Precious8-2 Chapter 35 Bowel Elimination PrepU78 terms Alejandra_Cantu09 Other sets by this creatorNMNC 4335126 terms brijchavPlus Nursing Process of Urinary Antiinfective: Trimetho…23 terms brijchavPlus Nursing Process of Antiulcer Drugs44 terms brijchavPlus Nursing Process of Maintenance of Homeostasis18 terms brijchavPlus Recommended textbook solutions
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What position should a patient be in to receive an enema quizlet?How should I position my patient for an enema? Assist your adult patient to a left side-lying (Sims') position with the right knee flexed for adequate exposure of the anus. A child, use the dorsal recumbent position.
Which position should the client be placed in prior to receiving a cleansing enema?Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.
Which client position does the nurse used to administer a cleansing enema?A) Place the patient in the dorsal recumbent position on a bedpan.
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When administering a cleansing enema the patient should be placed in the quizlet?
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