A nurse is preparing to administer a cleansing enema to an adult client in preparation

for a diagnostic procedure. Which of the following are appropriate steps for the nurse

to take? Select all.

A. Warm the enema prior to instillation

B. Position the client on the left side w/the right leg flexed forward

C. Lubricate the rectal tube or nozzle

D. Slowly insert the rectal tube about 2 inches

E. Hang the enema container 24 inches above the client's anus

A, B, C

Rational: D is the appropriate length of insertion for a child, 3-4 for an adult. 24

inches is too high & will cause it to run to fast & possible painful distention of the

colon, 18 inches is the recommended height

While a nurse is administering a cleansing enema, the client reports abdominal

cramping. Which of the following is the appropriate intervention?

A. Have the client hold his breath briefly

B. Discontinue the fluid instillation

C. Remind the client that cramping is common at this time

D. Lower the enema fluid container

D. Lower the enema fluid container

Rational: This will slow the rate of instillation & relieve some discomfort

A nurse is caring for a client who has been sitting in a chair for 3 hrs. Which of the

following problems is the client at risk for developing?

A. Stasis of secretions

B. Muscle atrophy

C. Pressure ulcer

D. Fecal impaction

Answer: C

Rational: Unrelieved pressure over a bony prominence for too long increases the

risk of a pressure ulcer, sitting will help prevent stasis of secretions

B and D-these are from prolonged bed rest

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