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Question

Difficulty: HardBasic Care and Comfort

A nurse is preparing to administer a large-volume cleansing enema to an adult client experiencing severe constipation. Arrange the following nursing actions in the correct chronological sequence of execution.

  1. 1Assist the client into a left lateral Sims position with the right knee flexed.
  2. 2Apply a water-soluble lubricant to the distal 3 to 4 inches of the rectal tube.
  3. 3Instruct the client to exhale gently while inserting the tip 3 to 4 inches toward the umbilicus.
  4. 4Hold the enema container 12 to 18 inches above the client's hips and open the roller clamp.
  5. 5Clamp the tubing or lower the container temporarily if the client reports severe abdominal cramping.

Answer

The correct sequence is: 1) position the client in the left lateral Sims position, 2) lubricate the tube, 3) insert the tube while the client exhales, 4) elevate the container to initiate flow, and 5) clamp or lower the container if cramping occurs.
The correct sequence for enema administration prioritizes safe anatomical positioning, proper preparation to minimize trauma, precise insertion technique, controlled gravity-based fluid delivery, and appropriate responsiveness to client complications such as cramping.

Step-by-Step Solution

1
Assist the client into a left lateral Sims position with the right knee flexed.
The client's descending colon is optimally positioned for gravity-assisted flow.
This alignment takes advantage of anatomical curves, allowing the enema solution to flow downward into the sigmoid colon.
2
Apply a water-soluble lubricant to the distal 3 to 4 inches of the rectal tube.
The tip of the enema tubing is coated and ready for smooth insertion.
Lubrication reduces friction, preventing damage to the delicate mucosal lining of the rectum and minimizing client discomfort.
3
Instruct the client to exhale gently while inserting the tip 3 to 4 inches toward the umbilicus.
The tube is safely placed into the rectum without forced resistance.
Exhaling relaxes the external anal sphincter. Directing the tube toward the umbilicus follows the natural anatomical angle of the rectum.
4
Hold the enema container 12 to 18 inches above the client's hips and open the roller clamp.
The enema solution begins flowing slowly into the colon.
Elevating the bag dictates the hydrostatic pressure. Placing it no higher than 18 inches ensures the fluid flows at a safe, tolerable rate.
5
Clamp the tubing or lower the container temporarily if the client reports severe abdominal cramping.
The flow is paused or slowed, reducing sudden bowel distention.
Cramping indicates rapid distention. Pausing or slowing the flow allows the bowel walls to accommodate the fluid volume.

Key Concept

Administration of a Large-Volume Cleansing Enema
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Topics

Basic Care and Comfort

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