An appropriate procedure for the nurse to implement while administering an enema is:
A. Keeping the solution at room temperature
B. Positioning the client on the right side
C. Raising the enema bag to 12 inches above the client
D. Instructing the client to release the enema solution as soon as possible
A
A. Add warmed solution to enema bag: warm tap water as it flows from faucet, place saline container in basin of hot water before adding saline to enema bag, and check temperature of solution by pouring small amount of solution over inner wrist.
B. Assist client into left side-lying (Sims') position with right knee flexed. Children may also be placed in dorsal recumbent position.
C. Raise height of enema container slowly to appropriate level above anus: 30 to 45 cm (12 to 18 inches) for high enema, 30 cm (12 inches) for regular enema, 7.5 cm (3 inches) for low enema. Instillation time varies with volume of solution administered (e.g., 1 L/10 min)
D. Ask client to retain solution as long as possible while lying quietly in bed.
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