The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema?
A) Tape the client's buttocks together so to retain the enema.
B) Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period.
C) Prop the client over a toilet to allow gravity to assist in the defecation process.
D) Insert the enema tubing high into the bowel to increase fecal mass elimination.
B
Feedback:
The best nursing action is to instill the enema solution slowly and allow a waiting period. By doing so, the enema solution has the best opportunity to be effective. The nurse would tape the buttocks together when administering a suppository. Propping the client over the toilet would allow the enema solution to be expelled immediately. Enema tubing is inserted carefully into the rectum and not advanced high into the colon.
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