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The nurse is administering an enema to a client. The nurse positions the client side-lying and inserts the lubricated tip of the enema applicator to a depth of:

Explanation

• Lubricate the enema applicator tip. Insert the lubricated enema tip  3-4 inches into the rectum and release the enema tubing clamp.

• Monitor the client for cramping and muscle tension as the solutions flows into the rectum. If the client reports discomfort, stop the flow for a few moments until it subsides. Massaging the abdomen can relieve some discomfort.  Massage in the direction that content moves along in the GI tract.

• Remove the tip of the enema from the rectum once it is empty. Have the client to remain laying down until he or she feels the need to void, then help him or her to the restroom. 

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