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a nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take?
lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube.
position the client on his right side.
insert the tip of the tubing 8 cm (3.1 in).
hold the enema container 61 cm (24 in) above the rectum.

Explanation:

When administering a cleansing enema, the nurse should lubricate 5 - 7.5 cm (2 - 3 inches) of the tip of the rectal tube, position the client on the left - side (Sims' position), insert the tip of the tubing 7 - 10 cm (2.75 - 4 inches), and hold the enema container 30 - 45 cm (12 - 18 inches) above the rectum. Lubricating only up to 3.2 cm is insufficient, right - side positioning is incorrect, and holding the container 61 cm above is too high. Inserting the tubing 8 cm (3.1 inches) is within the correct range.

Answer:

Insert the tip of the tubing 8 cm (3.1 in).