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. Hyperreflexia: Hypokalemia typically causes hyporeflexia, not hyperreflexia.
B. Increased appetite: Hypokalemia does not affect appetite; it can cause gastrointestinal symptoms like constipation.
C. Cardiac dysrhythmias: Low potassium levels can lead to dangerous cardiac dysrhythmias, making this the correct physiological response.
D. Hypoglycemia: Hypokalemia does not directly cause hypoglycemia.

A. Massage the injection site after administration of the medication. B. inject the medication into the abdomen above the level of the iliac crest C. Use a 1-inch needle to inject the medication. D. Use a 22-gauge needle to inject the medication.

Correct Answer is B

Explanation

A. Massage the injection site after administration of the medication. Massaging the site after heparin injection can cause bruising and should be avoided.
B. Inject the medication into the abdomen above the level of the iliac crest: This is the recommended site for subcutaneous heparin injections.
C. Use a 1-inch needle to inject the medication. A shorter needle (5/8 inch) is typically used for subcutaneous injections, not a 1-inch needle.
D. Use a 22-gauge needle to inject the medication: A smaller gauge needle (25 to 27 gauge) is typically used for subcutaneous injections, not 22-gauge.

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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

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

Correct Answer is C

Explanation

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?

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A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

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