The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?
A) The patient is recovering from a traumatic brain injury.
B) The patient has not had a bowel movement for 3 days.
C) The patient is to have a lower GI series the following morning.
D) The patient had an upper GI series performed the previous day.

Question

Quizplus · Accepted Answer

Patients with a traumatic brain injury often have increased intracranial pressure, which can be worsened with enema administration, thus putting the patient at risk for additional neurologic damage. The physician should be contacted and the order should be questioned. Constipation, preparation for a lower GI series, and removal of barium from the colon after upper GI series are all indications for a cleansing enema.

The Nurse Is Caring for a Patient Who Is to Have