Question

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

1) Lubricating the rectal tube before insertion
2) Inserting the tube 2 inches into the rectum
3) Administering the enema slowly over 30 minutes
4) Positioning the patient on the left side with knees flexed

Answer 1

The correct nursing action is to lubricate the rectal tube before insertion. Option 2 and 3 are incorrect. Option 4 is correct, positioning the patient on the left side with knees flexed.

Step-by-step explanation:

The correct nursing action in this procedure is to lubricate the rectal tube before insertion, as stated in option 1.

The rectal tube needs to be lubricated to make insertion more comfortable for the patient and to prevent any trauma or injury to the rectal tissue.

Option 2 states that the tube should be inserted 2 inches into the rectum, which is incorrect. The proper length of insertion depends on the patient's size and the specific procedure.

Option 3 states that the enema should be administered slowly over 30 minutes, which is incorrect. The enema should be administered as directed by the healthcare provider.

Option 4 states that the patient should be positioned on the left side with knees flexed, which is correct. This position helps to facilitate the insertion of the rectal tube and the administration of the enema.