Question

A nurse is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution?

1) Administer the enema solution at room temperature
2) Administer the enema solution while the client is lying on their left side
3) Administer the enema solution quickly to minimize discomfort
4) Administer the enema solution using a large volume

Answer 1

When administering an enema, the nurse should use a solution at room temperature, position the client on their left side, inject the solution slowly, and use an appropriate volume based on the type of enema.

Step-by-step explanation:

When administering an enema to a client who has constipation, a nurse should adhere to several key guidelines to ensure safety and effectiveness. First, the solution should be administered at a comfortable temperature; typically, room temperature is safe, but some protocols might recommend slightly warmer temperatures to help stimulate peristalsis. It's important not to use solutions that are too hot or too cold.

Second, the client should be positioned on their left side, known as the Sims' position, which aids in the flow of the solution due to the natural alignment of the rectum and sigmoid colon. Third, the enema should be administered slowly to minimize discomfort and reduce the risk of causing irritation or damage to the rectal mucosa. Lastly, the volume of the solution should be appropriate to the type of enema; 'large volume' enemas typically involve more fluid and are intended to cleanse the entire colon. However, it might be more appropriate to start with a smaller volume enema depending on the situation and the patient's condition.