A client is prescribed a saline enema. Because this solution is ...

[newbem]

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action?
 
  1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon
  2. Exerts a lower osmotic pressure than the surrounding interstitial fluid
  3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon
  4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon

Question 2

The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision?
 
  1. Bowel sounds active in all four quadrants
  2. Clay-colored stool
  3. Increased appetite
  4. Semisolid and moist stool

[ky860224]

Answer to Question 1

Correct Answer: 1
Rationale 1: A hypertonic solution exerts osmotic pressure and draws fluid from the interstitial space into the colon.
Rationale 2: A hypotonic solution exerts a lower osmotic pressure than the surrounding interstitial fluid.
Rationale 3: An isotonic solution is the safest enema solution to use. It exerts the same osmotic pressure as the interstitial fluid surrounding the colon.
Rationale 4: Soapsuds stimulate peristalsis by increasing the volume in the colon and irritating the colon.

Answer to Question 2

Correct Answer: 2
Rationale 1: Bowel sounds active in all four quadrants is indicative of normal bowel activity.
Rationale 2: Clay-colored stools would be an indication of a problem in the GI tract. Clay color is a sign of the absence of bile pigment (bile obstruction).
Rationale 3: If the GI tract were compromised, the client would have a decrease in appetite, not an increase.
Rationale 4: A semisolid and moist stool indicates normal bowel function.

[newbem]

Excellent

[FergA]

TYSM