ATI RN
RN ATI Fundamentals of Nursing Questions
Extract:
Question 1 of 5
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Hold the container of solution 30 cm (12 in) above the anus. This is the correct action because gravity is needed to facilitate the flow of the enema solution into the client's rectum. By holding the container 30 cm above the anus, the nurse ensures that there is enough pressure to allow the solution to flow effectively. Holding it at a higher level could cause the solution to flow too quickly, leading to discomfort or injury.
Choices B, C, and D are incorrect because they do not provide the optimal height for the solution to flow effectively. Holding the container 15 cm above the anus and then lowering it may not provide enough pressure, holding it level with the client's upper hip may not allow for sufficient gravity, and keeping it at a level for client comfort may not be effective in administering the enema properly.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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