The nurse is administering a cleansing enema. Which action would indicate the need for further instruction on the process?
1. Enema solution is warmed to 40 °C (105 °F).
2. The solution container is held 12 inches above the rectum.
3. 1,000 mL of fluid is administered over 30 minutes.
4. The client is encouraged to retain the enema for 5-10 minutes.
Correct Answer: 3
The fluid should be administered over 10-15 minutes, not 30 minutes. The remaining actions are correct.
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