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. The client is in the Fowler's position.
4. The client is encouraged to retain the enema for 5–10 minutes.
3
Rationale 1: The solution should be warmed.
Rationale 2: The container should be about 12 inches above the rectum.
Rationale 3: The client should be in the Sim's position for the enema.
Rationale 4: The enema should be retained for 5 to 10 minutes.
Global Rationale: The client should be in the Sim's position for the enema. The solution should be warmed. The container should be about 12 inches above the rectum. The enema should be retained for 5 to 10 minutes.
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