Practice Question
A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Answer Choices:
Rationale:
“Confirm the client's identity by checking her wristband.”
🔷 The first step is always to verify the right client using at least two identifiers, commonly name and wristband.
🔷 This prevents performing the enema on the wrong person, which would be a serious patient safety event.
🔷 Correct identification aligns with standard safety protocols such as the “five rights” of procedures and treatments.
🔷 Performing any intervention without confirming identity increases risk for legal and clinical errors.
🔷 Therefore, this step must occur before any further action in the enema procedure.
“Provide for the client's privacy by closing the curtains.”
🔷 Once identity is confirmed, the nurse must protect the client’s privacy by closing curtains or the door.
🔷 Enema administration is an intimate procedure, and maintaining dignity and modesty is part of professional, patient-centered care.
🔷 Privacy encourages the client to feel more comfortable and cooperative during the procedure.
🔷 It also reduces environmental distractions and avoids unnecessary exposure to others in the room or hallway.
🔷 Thus, privacy is appropriately addressed before positioning and insertion.
“Assist the client into the Sims' position.”
🔷 The left Sims' position allows the enema solution to flow by gravity into the sigmoid colon more effectively.
🔷 Proper positioning enhances comfort, solution retention, and effectiveness of the enema.
🔷 Positioning must be completed before inserting the tubing to avoid injury or discomfort.
🔷 This step also helps the nurse assess the client’s mobility, tolerance, and skin integrity.
🔷 Therefore, placing the client in Sims' position is logically done after privacy and before insertion.
“Insert the tip of the enema tubing into the client's rectum.”
🔷 Insertion is performed only after the client is identified, privacy is ensured, and proper positioning is achieved.
🔷 The nurse gently inserts the lubricated tip of the tubing to reduce mucosal trauma and discomfort.
🔷 This step involves direct access to the rectum, so it must be done last in the sequence to maintain both dignity and safety.
🔷 Inserting before privacy or positioning would be unsafe and unprofessional.
🔷 Therefore, insertion is the final procedural step in this ordered sequence.
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This question is from Custom Fundamentals Exam 4 Fall 2025 which contains 24 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4