While administering an enema, the client complains of abdominal cramping. What should the nurse do?
1. Raise the height of the solution container.
2. Clamp the flow for 30 seconds, and restart at a slower rate.
3. Discontinue the enema infusion.
4. Assist the client to a supine position.
Correct Answer: 2
Rationale 1: Raising the height of the enema solution container will cause the solution to infuse faster, leading to more abdominal cramping.
Rationale 2: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution.
Rationale 3: The enema should not be discontinued.
Rationale 4: The supine position will not reduce the client's abdominal cramping.
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