A nurse is caring for an elderly client experiencing gastrointestinal discomfort.

Exhibits

Select the appropiate client instructions for the administration of enemas

Rationale:
A. Tap water enemas are hypotonic, and repeated or large-volume use can lead to hyponatremia or other electrolyte disturbances, particularly in infants, elderly clients, or those with renal or cardiac issues.

B. Administering a tap water enema in a client with suspected appendicitis can increase intra-abdominal pressure, potentially causing perforation or worsening the condition.

C. Tap water enemas can further disrupt fluid and electrolyte balance in clients who are already dehydrated, exacerbating their condition.

D. Regular use of laxatives is not a strict contraindication for a tap water enema but may reduce its effectiveness over time due to bowel adaptation.

E. Clients with recent bowel surgery or structural abnormalities are at higher risk for perforation or injury when receiving an enema.

F. Tap water enemas are not indicated for clients with normal bowel function because they are unnecessary and can cause discomfort or dependence.

G. While maintaining hydration is important, it does not contraindicate the use of a tap water enema; it may actually support bowel function.

Rationale:
A. After the return of bowel sounds postoperatively, clear liquids (e.g., water, broth, tea, clear juice) are introduced first. This allows the gastrointestinal tract to gradually resume function and ensures the client can tolerate fluids without nausea, vomiting, or distention.

B. A soft diet is introduced later once the client tolerates clear liquids and then full liquids, as it is more complex to digest.

C. A regular diet is not started immediately after surgery; the gut needs gradual reintroduction to food.

D. Full liquids can be given after clear liquids are tolerated, as they are more substantial and include milk-based or blended foods.