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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Increased salivation: Hypernatremia often causes dry mouth and decreased salivation.
B. Cool, clammy skin: Hypernatremia does not typically cause cool, clammy skin; this is more associated with hypovolemia.
C. Hypertension: While hypertension can occur, it is not as specific as decreased level of consciousness.
D. Decreased level of consciousness: Severe hypernatremia can lead to neurological changes, including decreased level of consciousness. Excess sodium draws water out of cells, leading to dehydration inside the cells, especially in the brain. Decreased brain cell function due to dehydration can manifest as confusion, lethargy, and potentially a decreased level of consciousness in severe cases (coma).
Correct Answer is B
Explanation
A. Decreased calcium level: NG tube drainage primarily affects sodium, potassium, and chloride levels rather than calcium.
B. Decreased potassium level: Large volumes of gastric drainage can result in significant potassium loss, leading to hypokalemia.
C. Elevated magnesium level: NG tube drainage does not typically cause elevated magnesium levels.
D. Elevated sodium level: NG tube drainage is more likely to cause decreased sodium levels due to fluid loss and electrolyte imbalance.
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