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

procedure. Whichof thefollowingareappropriatestepsfor thenurseto take? Select all.

A. Warm theenemaprior toinstillation

B. Positiontheclientontheleftside w/theright legflexedforward

C. Lubricatetherectal tubeornozzle

D. Slowly insert therectal tube about2inches

E. Hangthe enemacontainer24inchesabovetheclient's anusA, B, C

Rational: D is the appropriate length of insertion fora child, 3-4 foran adult. 24

inches is too high & willcause it to run to fast & possible painful distention of thecolon, 18 inches is

the recommended height

While anurseisadministering acleansingenema, theclient reportsabdominalcramping. Whichof the

following is the appropriate intervention?

A. Have theclientholdhis breathbriefly

B. Discontinuethefluidinstillation

C. Remindtheclient thatcrampingiscommonat this time

D. Lower theenemafluidcontainer

D. Lower theenemafluidcontainer

Rational:This willslow the rate of instillation & relieve some discomfort

A nurseiscaringforaclient whohas beensittinginachair for 3 hrs. Whichof thefollowing problems is the

client at risk for developing?

A. Stasisofsecretions

B. Muscleatrophy

C. Pressureulcer

D. Fecal impaction

Answer: C

Rational: Unrelieved pressure overa bony prominence fortoo long increases the

risk ofa pressure ulcer,sitting will help preventstasis ofsecretionsB and D-these

are from prolonged bed rest