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Zorluk: KolayBasic Care and Comfort

A licensed practical nurse is preparing to administer a prescribed large-volume cleansing enema to an adult client who is experiencing constipation. In what order should the nurse perform the following actions? Arrange the steps from first to last.

  1. 1Assist the client into the left lateral Sims position.
  2. 2Apply a water-soluble lubricant to the tip of the enema tubing.
  3. 3Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the client's rectum.
  4. 4Open the clamp on the tubing and allow the solution to flow slowly.

Cevap

The correct sequence is to first position the client in the left lateral Sims position, then lubricate the tip of the tubing, gently insert the tubing into the rectum, and finally open the clamp to allow the solution to flow.
The correct sequential order for administering an enema ensures client safety, promotes comfort, and maximizes the procedure's efficacy. Positioning the client properly in the left lateral Sims position must always come first to physically prepare the client and utilize gravity for the bowel's anatomical curve. Next, lubricating the tube is an essential safety measure that must be completed immediately before any contact is made with the body to prevent mucosal damage. After lubrication, the tube is safely and gently inserted 3 to 4 inches into the rectum. Finally, only once the tube is correctly placed and secured by the nurse's hand, the clamp is opened to begin the instillation of the fluid.

Adım Adım Çözüm

1
Assist the client into the left lateral Sims position.
The client is positioned appropriately for the procedure.
This position follows the natural curve of the descending colon and sigmoid colon, utilizing gravity to help the fluid flow inward.
2
Apply a water-soluble lubricant to the tip of the enema tubing.
The tubing tip is slick and ready for insertion.
Lubrication is essential to reduce friction and prevent trauma or tearing of the delicate rectal mucosa during insertion.
3
Gently insert the tubing 3 to 4 inches (7.5 to 10 cm) into the client's rectum.
The tube is placed at the correct depth within the rectum.
Proper insertion depth ensures the fluid is delivered past the internal and external sphincters without causing injury or perforation.
4
Open the clamp on the tubing and allow the solution to flow slowly.
The enema solution begins to instill into the colon.
Opening the clamp initiates the actual treatment. Flowing the fluid slowly prevents sudden bowel distension, which can cause severe cramping.

Anahtar Kavram

Basic Care and Comfort: Enema Administration Sequence
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