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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 the container of solution level with the client's upper hip.

D.

Keep the container of solution at a level to maintain client comfort.

Answer and Explanation

The Correct Answer is A

A.    This is the appropriate height to allow the fluid flow by gravity.
B.    This is such a short distance and the fluid wouldn't flow as desired.
C.    Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D.    This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.
 


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Related Questions

Correct Answer is ["A","B","C"]

Explanation

A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.

Correct Answer is A

Explanation

A. When administering a cleansing enema, it is important to hold the container of solution about 30 cm (12 in) above the anus. This provides enough gravitational force for the solution to flow gently into the rectum.
B. This action involves unnecessary movement of the container and is not a standard technique for administering a cleansing enema.
C. Holding the container level with the client's upper hip does not provide sufficient height for the gravitational force needed to administer the enema effectively.
D. Keeping the container at a level to maintain client comfort is not specific guidance for administering a cleansing enema. The height of the container above the anus is a critical factor in ensuring the enema flows properly.

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