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The Nursing Assistant Prepares to Administer the Soap Suds Enema

Question 8

Multiple Choice

The nursing assistant prepares to administer the soap suds enema and asks the resident to take a deep breath and exhale slowly before inserting the lubricated enema tip. A bleeding loop of bowel prolapses (protrudes) outside the rectum. What is the priority action for the nursing assistant to take?


A) Insert the lubricated tip 3 to 4 inches without any resistance toward the resident's umbilicus.
B) Stop the procedure and report the observation immediately to the nurse.
C) Double-check if the clamp may be adjusted by the nursing assistant before insertion.
D) Determine whether the bedpan is nearby in case the resident needs it during the administration of the enema.

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