05 November, 2007 An enema is a liquid preparation that is introduced into the body via the rectum for the purposes of producing a bowel movement or administering medication. Kyle, G. (2007) Bowel care part 4. Administering an enema. Nursing Times; 103: 45, 26-27. Keywords: Gastrointestinal, enema, bowel… To continue reading this clinical article please log in or subscribe. Subscribe for unlimited access
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Already have an account, click here to sign in Ian Peate Professor of nursing, Gibraltar Health Authority, GibraltarRationale and key points This article aims to help nurses to undertake the administration of enemas in a safe, effective and patient-centred manner, ensuring privacy and dignity. The administration of an enema is a common healthcare procedure, which can be used to deliver medication or aid bowel evacuation. ▶The administration of an enema should be undertaken by a competent nurse. ▶An enema is a liquid preparation inserted into the rectum. ▶The nurse must explain the procedure to the patient and should assist the individual before, during and after the procedure. ▶The nurse should document all care given. Reflective activity Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1.How you felt performing this intimate procedure. 2.The positive elements of care delivery and those that could be enhanced. Subscribers can upload their reflective accounts at: rcni.com/portfolio. Nursing Standard. 30, 14, 34-36. doi: 10.7748/ns.30.14.34.s43 Correspondence
Peer review All submissions are subject to external double-blind peer-review and checked for plagiarism using automated software. Received: 29 June 2015 Accepted: 17 September 2015 Want to read more?Already subscribed? Log inORUnlock full access to RCNi Plus todaySave over 50% on your first 3 monthsYour subscription package includes:
Subscribe RCN student member? Try Nursing Standard StudentAlternatively, you can purchase access to this article for the next seven days. Buy now Or Fundamentals Final 1*A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Have the client demonstrates the procedure. Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning. 2*A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Position the client on his left side. Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon. 3*A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Observe the rate, depth, and character of the client's respirations. The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status. 4*A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding. 5*A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Lower the client to the floor and place a pad under the clients head. To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head. 6*A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Educating clients about the recommended immunization schedule for adults. Primary prevention includes health education about disease prevention. 7*An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates for further teaching? The AP hangs the collection bag at the level of the bladder. The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity. 8*A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Romberg Test When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test. 9*A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Washing dishes Washing dishes requires a low level of activity and is appropriate for this client. Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first. 15*A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction? Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. 16*A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Tachycardia Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen- carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate. 17*A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Bounding pulse Bounding pulse is an expected finding of fluid volume excess. 18*A nurse is caring for a client who has clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown 19*A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread his feet apart because a wide base of support increases stability. 20*A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "All of this equipment can be frightening." This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more. 21*A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings. 22An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Tell me more about how your friends discourage you." 23*A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pain in the periumbilical area. The nurse should plan care bases on which of the following factors contributing to this postoperative complications? Impaired peristalsis of the intestines Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis. 24*A hospice nurse is reviewing religious practices of a group of clients with newly licensed nurse indicates an understanding of the teaching? "People who practice Judaism stay with the body of the deceased until burial." In the Jewish faith, a family member often stays with the body until burial occurs. The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe. 30*A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm This finding is above the expected reference range and is an indication of infection. 31*A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Bear weight on both of your legs." The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs. 32*A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels. 33*A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include> 10-month-old infant can pull up to a standing position 34*A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider had prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit. 35*A nurse is caring for a client who has a terminal illness. which of the following findings indicates that the client's death is imminent? Cold extremities Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent. 36*A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I can see that this is upsetting you." The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client. 37*A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Oil retention The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. 38*A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs. 39*A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made. Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature. 43*A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. 44*A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration. 45*A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Provide a protein intake to 1/kg of the body weight per day. A protein intake of 1 to 1 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. 46*A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? PC for after meals The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation. 47*A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Wear cotton clothing to avoid static electricity 48*A nurse in a provider's office is collecting information form an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects. Liver damage Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2 grams per day for older adults and those with a history of liver impairment. 49*A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes and apologizes for smell. Which of the following responses should the nurse make? It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings. 50*A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps. What are the nursing consideration in administering enema procedure?Nursing Interventions for Enema Administration. Check the doctor's order.. Provide privacy. ... . Promote relaxation. ... . Position the client:. Sizes of rectal tube to be used are as follows:. Lubricate 5 cm (2 in) of the rectal tube.. Which is a nursing priority when administering an enema to a client?Which nursing assessment takes priority when administering an enema to a client? The enema may stimulate a vagal response, which increases parasympathetic stimulation.
What procedure should you follow if a patient experiences discomfort during an enema?Pain may be the result of hemorrhoids or tears in the rectal lining. If you experience pain when inserting the enema tube or pushing the fluid into your colon, stop the enema immediately and call your healthcare provider or local medical services.
When administering an enema the client should be?The left lateral position is the most appropriate position for giving an enema because of the anatomical characteristics of the colon.
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Which action would the nurse take if there are concerns during administration of the enema?
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