While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:
1. Immediately stop the infusion
2. Lower the height of the enema container
3. Advance the enema tubing 2 to 3 inches
4. Clamp the tubing
ANSWER
ANS: 2
The nurse should lower the container if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of the fluid, and the enema will be less effective. The nurse may slow the infusion until the abdominal cramping passes. The enema tubing should not be advanced further. The tubing may be clamped temporarily if fluid escapes around the rectal tube. The instillation should be slowed in the instance of abdominal cramping.
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