The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions?
1. Discontinue the enema.
2. Reassure the client, and continue the flow.
3. Raise the enema bag so that the solution can be completed quickly.
4. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.
4
Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, stop the flow for 30 seconds and restart at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore "discontinue the enema," "reassure the client, and continue the flow," and "raise the enema bag so that the solution can be completed quickly" are incorrect actions.
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