Care Manager Certification Practice Exam

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When administering a cleansing enema, how high should the nurse hold the solution container?

15cm (6in) above the anus
30cm (12in) above the anus
Level with the client's upper hip
15cm (6in) below the anus

The correct answer is: 30cm (12in) above the anus

When administering a cleansing enema, the nurse should hold the solution container about 30 cm (12 inches) above the anus. This height allows gravity to assist in the flow of the solution into the rectum and can effectively promote the desired cleansing action. If the container is positioned correctly at this height, the pressure created will help ensure that the fluid reaches the lower colon, effectively doing its job in preparation for examinations or relieving constipation. Holding the container at the specified height is crucial for achieving the intended results of the enema while also minimizing discomfort for the patient. Positioning the container too low may lead to inadequate solution delivery, while positioning it too high can cause too rapid a flow, potentially leading to discomfort or complications. Therefore, the guidance on this practice emphasizes the appropriate height for the container to ensure a safe and effective procedure.