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 B
Explanation
A. Prone: The prone position is not conducive for administering a rectal suppository.
B. Sim's: Sim's position (lying on the left side with the right knee bent) allows for easier access to the rectum and promotes comfort during administration.
C. Dorsal recumbent: This position is not ideal for rectal suppository administration.
D. Fowler's: Fowler's position is used for feeding and respiratory treatments, not for administering rectal medications.
Correct Answer is A
Explanation
A. Dispose of the needle uncapped: The safest method to avoid needle-stick injuries and potential exposure to bloodborne pathogens, including hepatitis C, is to dispose of the needle immediately without recapping.
B. Ask another nurse to recap the needle: Asking another nurse to recap the needle still poses a risk of needle-stick injury and is not a recommended practice.
C. Place the cap on the table and slide the needle into the cap: This method, known as the "scoop" technique, reduces the risk compared to hand recapping but is still not the best practice. Proper sharps disposal is the preferred method.
D. Recap the needle: Recapping needles is discouraged due to the high risk of accidental needle-stick injuries.
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