A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?
Explanation & Rationale
Choice A reason: Positioning on the right side is incorrect; the left side (Sim’s position) allows better solution flow into the colon. Right-side positioning hinders distribution, making this incorrect for enema administration. Choice B reason: Cold tap water can cause cramping or shock. Warm water (105–110°F) ensures comfort and safety, making cold water incorrect for a cleansing enema solution. Choice C reason: Inserting tubing 4 inches is excessive; 2–3 inches is sufficient for adults to reach the rectum safely. Deeper insertion risks injury, making this incorrect for proper technique. Choice D reason: Holding the container 12 inches above the anus ensures safe, controlled flow, preventing pressure-related discomfort or injury. This standard height is correct for effective enema administration.