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.
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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Related Questions
Correct Answer is C
Explanation
A. Order a lunch tray for the client. Before advancing the diet, it is important to assess the client's readiness, particularly bowel sounds.
B. Offer the client apple juice. Providing liquids is appropriate only after assessing the client's gastrointestinal function.
C. Auscultate the client's abdomen: This assessment checks for the return of bowel sounds and gastrointestinal function, indicating whether the client can tolerate clear liquids.
D. Elevate the client's head of bed. While positioning is important, the primary first step is to assess the client's gastrointestinal status
Correct Answer is B
Explanation
not to remove gastric acid but to assess tolerance to feedings.
B. To identify delayed gastric emptying: Measuring gastric residual volume helps identify delayed gastric emptying, which can indicate a risk of aspiration or intolerance to the feeding.
C. To confirm the placement of the NG tube: Tube placement should be confirmed by other means, such as pH testing or X-ray, rather than measuring residual.
D. To determine the client's electrolyte balance: Measuring gastric residual does not provide information about the client's electrolyte balance.
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