The nurse assigns ancillary personnel the task of giving a client a pr

The nurse assigns ancillary personnel the task of giving a client a pre-procedure enema. Which of the following statements made by the personnel requires immediate follow-up by the nurse?

1. “I use all of the soap provided in the kit.”
2. “The soapy water just came right back out.”
3. “An enema is intended to clean out the rectum.”
4. “The client was able to hold the enema for 5 minutes.”

ANSWER

ANS: 2
An enema is an example of an instillation whereby the fluid is retained for a period of time to facilitate a therapeutic response. What the ancillary personnel was describing was an irriga-tion—the liquid runs over or into the area and is allowed to immediately flow away. Options 1, 3, and 4 are correct and do not require follow-up.