A nurse is assessing a client who has urinary retention.Which of the following findings should the nurse expect?

Choice B rationale

Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping, making the procedure less tolerable for the client.

Choice A rationale

Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the solution into the colon.

Choice C rationale

Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.

Choice D rationale

Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the absorption of the enema solution. Water-soluble lubricants are preferred.

Choice A rationale

Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.

Choice B rationale

Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.

Choice C rationale

Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.

Choice D rationale

Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.