9. A nurse is administering a high cleansing enema. At what level above the client's hips would the nurse place the enema bag? A. 4 inches (10 cm) B. 8 inches (20 cm) C. 10 inches (25.5 cm) D. 18 inches (45.5 cm) 80. The primary healthcare provider (PHCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, the client is still passing brown stool and fluid. Which action would the nurse take? A. Notify the PHCP. B. Continue administering enemas until the fluid returns clear. C. Administer a glycerin suppository and then administer one more enema. D. Allow the client to rest for 1 hour and then continue with another enema. 81. A nurse is preparing to administer a soapsuds enema to an adult client. After explaining the procedure and positioning the client, the nurse inserts the rectal tube into the client's rectum a maximal distance of how many inches? A. 1½ inches (3.8 cm)
Answer (1)
For question 9, which asks at what level above the client's hips a nurse would place the enema bag for a high cleansing enema, the correct answer is D. 18 inches (45.5 cm) .
When administering a high cleansing enema, the enema bag is typically placed 12 to 18 inches above the patient's hips. The higher placement allows the solution to flow into the colon more effectively, which helps cleanse a larger portion of the colon.
For question 80, which involves the scenario where a nurse has administered three enemas and the client is still passing brown stool and fluid, the correct action would be A. Notify the PHCP .
It is crucial to notify the primary healthcare provider if the enema solution fails to clear after several attempts. Continuing to administer more enemas without consulting a healthcare provider can lead to complications or discomfort for the patient.
For question 81, concerning the insertion depth of a rectal tube during a soapsuds enema for an adult client, the correct answer is not given among the options, but typically, a rectal tube is inserted approximately 3 to 4 inches (7.5 to 10 cm) into the rectum for an adult.
Inserting the tube to this depth ensures that the solution is delivered effectively while minimizing discomfort and avoiding injury to the rectal lining.
