A nurse is teaching a client who has a new prescription for an albuterol inhaler. Which of the following instructions should the nurse include?

Choice A reason: Positioning on the right side is incorrect; the left side (Sim’s position) allows better solution flow into the colon. Right-side positioning hinders distribution, making this incorrect for enema administration.

Choice B reason: Cold tap water can cause cramping or shock. Warm water (105–110°F) ensures comfort and safety, making cold water incorrect for a cleansing enema solution.

Choice C reason: Inserting tubing 4 inches is excessive; 2–3 inches is sufficient for adults to reach the rectum safely. Deeper insertion risks injury, making this incorrect for proper technique.

Choice D reason: Holding the container 12 inches above the anus ensures safe, controlled flow, preventing pressure-related discomfort or injury. This standard height is correct for effective enema administration.

Choice A reason: Administering diphenhydramine treats allergic symptoms but does not address the ongoing transfusion reaction. Stopping the transfusion prevents further allergen exposure, making this a secondary action.

Choice B reason: Stopping the transfusion is the first action, as itching and hives indicate an allergic reaction. Halting the infusion prevents worsening symptoms, like anaphylaxis, making this the priority intervention.

Choice C reason: Notifying the provider is necessary but follows stopping the transfusion. Ceasing the infusion immediately mitigates the reaction, ensuring patient safety, making notification a subsequent step.

Choice D reason: Obtaining vital signs provides data but delays addressing the reaction. Stopping the transfusion halts allergen administration, taking precedence over assessment, making this a secondary action.