Question

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are appropriate steps for the nurse to take? Select all.

A. Warm the enema prior to instillation
B. Position the client on the left side w/the right leg flexed forward
C. Lubricate the rectal tube or nozzle
D. Slowly insert the rectal tube about 2 inches
E. Hang the enema container 24 inches above the client's anus

Answer 1

The appropriate steps for a nurse to take when administering a cleansing enema are warming the enema, positioning the client, lubricating the rectal tube, slowly inserting the rectal tube, and hanging the enema container.

Step-by-step explanation:

For administering a cleansing enema to an adult client in preparation for a diagnostic procedure, the nurse should take the following appropriate steps:

1. Warm the enema: Warming the enema solution helps to make the procedure more comfortable for the client.
2. Position the client: The client should be positioned on the left side with the right leg flexed forward. This position helps facilitate the flow of the enema solution.
3. Lubricate the rectal tube or nozzle: Lubricating the rectal tube or nozzle before insertion helps to ease the process and prevent injury.
4. Slowly insert the rectal tube: The rectal tube should be inserted about 2 inches into the rectum to ensure proper administration of the enema solution.
5. Hang the enema container: The enema container should be hung approximately 24 inches above the client's anus to allow for proper flow and gravity-assisted administration of the solution.