{"id":142864,"date":"2024-09-22T17:16:37","date_gmt":"2024-09-22T17:16:37","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=142864"},"modified":"2024-09-22T17:16:40","modified_gmt":"2024-09-22T17:16:40","slug":"a-nurse-is-preparing-to-administer-a-cleansing-enema-to-a-client-4","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/22\/a-nurse-is-preparing-to-administer-a-cleansing-enema-to-a-client-4\/","title":{"rendered":"A nurse is preparing to administer a cleansing enema to a client."},"content":{"rendered":"\n

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?<\/p>\n\n\n\n

A Hold the container of solution 30 cm (12 in) above the anus.
B Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.
C Hold the container of solution level with the client’s upper hip.
D Keep the container of solution at a level to maintain client comfort.<\/p>\n\n\n\n

The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n

The correct answer is B: Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.<\/strong><\/p>\n\n\n\n

Explanation:<\/h3>\n\n\n\n

When administering a cleansing enema, the nurse must consider the appropriate height for the enema bag to ensure effective delivery of the solution into the rectum. The height at which the enema bag is held directly impacts the flow rate of the solution, which can affect the comfort and effectiveness of the procedure.<\/p>\n\n\n\n

Rationale for Option B:<\/strong>
Holding the container 15 cm (6 inches) above the anus initially allows for a controlled flow of the solution into the rectum. This position helps create enough pressure for the solution to flow effectively without causing discomfort. By then lowering the container 15 cm below the anus, the nurse can facilitate a smoother delivery, reducing the risk of cramping or discomfort for the client. This gradual adjustment helps in managing the volume and pressure, making the experience more tolerable.<\/p>\n\n\n\n

Analysis of Other Options:<\/strong><\/p>\n\n\n\n

    \n
  • A (Hold the container of solution 30 cm (12 in) above the anus):<\/strong> Holding the container too high can increase the pressure too much, leading to cramping and discomfort, and may cause rapid infusion, which can be distressing for the client.<\/li>\n\n\n\n
  • C (Hold the container of solution level with the client’s upper hip):<\/strong> This position may not provide enough gravitational force for effective administration, potentially leading to inadequate cleansing.<\/li>\n\n\n\n
  • D (Keep the container of solution at a level to maintain client comfort):<\/strong> While comfort is important, the solution must still be delivered effectively. Comfort cannot be the sole criterion for positioning; the mechanics of gravity and pressure must also be considered to ensure that the enema is administered correctly.<\/li>\n<\/ul>\n\n\n\n

    In summary, proper positioning of the enema solution container is critical for the success of the procedure and the comfort of the client. The correct height allows for a safe and effective cleansing process.<\/p>\n","protected":false},"excerpt":{"rendered":"

    A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? A Hold the container of solution 30 cm (12 in) above the anus.B Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.C Hold […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-142864","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142864","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=142864"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/142864\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=142864"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=142864"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=142864"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}