A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Pause the enema and give the client pain medication.

Discontinue the enema.

Continue the enema and reassure the client.

Lower the height of the solution bag.

Answer and Explanation

The Correct Answer is D

A. Pause the enema and give the client pain medication. Pain medication is not appropriate for mild cramping caused by an enema.
B. Discontinue the enema. Stopping the enema entirely may not be necessary and could prevent the procedure from being effective.
C. Continue the enema and reassure the client. Continuing the enema without adjustment may cause increased discomfort.
D. Lower the height of the solution bag. Lowering the height of the enema bag can reduce the flow rate, easing cramping and discomfort.

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Correct Answer is C

Explanation

A. Select a 5/8-inch needle: A 5/8-inch needle is too short for an IM injection in an adult, as it may not reach the muscle tissue adequately.
B. Choose a 25-gauge needle: A 25-gauge needle is too small for an IM injection, as it may make the administration of a 3 mL volume difficult and painful.
C. Locate the ventrogluteal site: The ventrogluteal site is a preferred site for IM injections because it is free of major nerves and blood vessels and can accommodate larger volumes like 3 mL.
D. Inject at a 45° angle: IM injections should be administered at a 90° angle to ensure the medication is delivered into the muscle tissue.

A. Purplish colored stoma B. No stool noted in the collection bag C. Edematous stoma D. Slight bleeding of the stoma site

Correct Answer is A

Explanation

A. Purplish colored stoma: A purplish colored stoma indicates compromised blood flow and possible necrosis, which is an emergency and must be reported immediately.
B. No stool noted in the collection bag: It is normal for there to be no stool in the collection bag 12 hours postoperatively as bowel function may not yet have resumed.
C. Edematous stoma: Edema of the stoma is common in the immediate postoperative period and usually subsides with time.
D. Slight bleeding of the stoma site: Slight bleeding at the stoma site can be normal immediately after surgery due to the manipulation of tissues.

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A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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