The practical nurse (PN) is administering a saline enema to a client who was admitted
because of a fever of unknown origin and is now constipated. Which techniques should
the PN use? (Select all that apply.)
A.
Position client in left lateral recumbent position to expose buttocks.
B.
Chill the enema solution to help reduce the client’s fever.
C.
Encourage client to retain solution for at least 5 minutes.
D.
Insert lubricated tip of tubing 3 to 4 inches into the rectum.
The correct answer and Explanation is :
The correct answers are A, C, and D.
Explanation:
A. Position client in left lateral recumbent position to expose buttocks.
Positioning the client in the left lateral recumbent position is an important technique for administering an enema. This position helps to facilitate the flow of the solution into the rectum and colon due to the natural anatomical structure of the colon. It also provides easier access to the rectal area for the healthcare provider.
B. Chill the enema solution to help reduce the client’s fever.
This option is incorrect. The enema solution should be administered at room temperature or slightly warmed, as chilled solutions can cause cramping and discomfort, and may not effectively contribute to fever reduction. The purpose of the saline enema is to relieve constipation, not to affect fever management directly.
C. Encourage client to retain solution for at least 5 minutes.
Encouraging the client to retain the saline enema for at least 5 minutes is crucial for effective stool softening and bowel evacuation. Retaining the solution allows the saline to work by drawing water into the colon, which helps soften the stool and stimulate bowel movements.
D. Insert lubricated tip of tubing 3 to 4 inches into the rectum.
This technique is correct as well. Proper insertion of the lubricated tubing is essential for minimizing discomfort and preventing trauma to the rectal mucosa. Inserting the tip 3 to 4 inches ensures that the solution is delivered effectively into the rectum and the lower colon, facilitating the desired therapeutic effect.
In summary, for a client who is constipated, using the correct positioning, encouraging retention of the solution, and ensuring proper insertion technique are vital components of administering a saline enema safely and effectively.