What should the nurse instruct a client prior to administering a cleansing enema?
1. Hold the solution for a short time.
2. Lie in the left lateral position.
3. Lie in the right lateral position.
4. Take fast breaths through the nose.
Correct Answer: 2
Rationale 1: Once the enema is given, the client should hold the solution as long as possible for the best results.
Rationale 2: The client lies in the left lateral positionin order to clean the rectum and sigmoid.
Rationale 3: The client lies in the left lateral position, not the right, in order to clean the rectum and sigmoid.
Rationale 4: The client should take slow deep breaths through the mouth. This will enable the client to hold the solution being given.
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