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 B

Explanation

A. Introduce a regular diet: Introducing a regular diet is important but not the immediate priority.
B. Assess fluid balance: Assessing fluid balance is the priority to determine the extent of dehydration and guide rehydration therapy.
C. Rehydrate: Rehydration is crucial, but assessing fluid balance is necessary first to determine the appropriate rehydration method.
D. Maintain fluid therapy: Maintaining fluid therapy is important but comes after assessing the fluid balance to tailor the treatment accurately.

A. Decreased BUN B. Increased urine specific gravity C. Increased urine ketones D. Decreased hematocrit

Correct Answer is B

Explanation

A. Decreased BUN: Fluid volume deficit typically leads to increased BUN (blood urea nitrogen) due to hemoconcentration.
B. Increased urine specific gravity: Increased urine specific gravity indicates more concentrated urine, which is a common finding in fluid volume deficit.
C. Increased urine ketones: Increased urine ketones are associated with conditions like diabetes and starvation, not specifically fluid volume deficit.
D. Decreased hematocrit: Fluid volume deficit usually results in increased hematocrit due to hemoconcentration.

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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

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