A nurse is preparing to administer a large-volume cleansing enema to a client who is experiencing severe constipation. In what order should the nurse perform the following procedural steps? (Arrange from first to last.)
- 1Assist the client into the left lateral Sims' position.
- 2Apply water-soluble lubricant to the distal tip of the rectal tube.
- 3Insert the tube gently 3 to 4 inches into the rectum, angling toward the umbilicus.
- 4Raise the enema container 12 to 18 inches above the level of the anus.
- 5Release the clamp on the tubing to begin the flow of the solution.
Answer
The correct sequence is: assist the client into the left lateral Sims' position, lubricate the tip of the rectal tube, insert the tube into the rectum, raise the enema container to the proper height, and release the clamp.
The correct sequence aligns with standard clinical practice guidelines for safely administering a large-volume enema. The nurse must first ensure the client is in the proper anatomical position (left lateral Sims) to facilitate gravity flow. Next, the equipment must be prepared by lubricating the tube tip to prevent trauma. The tube is then safely inserted into the rectum. Once inserted, the container is raised to the correct height (12 to 18 inches) to control hydrostatic pressure, and finally, the clamp is released to instill the fluid.
Step-by-Step Solution
Key Concept
Procedural Sequence for Enema Administration
Estimated Time:1m 30s