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 A

Explanation

A. Urine output 20 mL/hr: Oliguria, or low urine output (less than 30 mL/hr), is a common sign of dehydration.
B. Bradycardia: Dehydration typically causes tachycardia (increased heart rate) as the body compensates for decreased blood volume.
C. Sodium 142 mEq/L: A sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) and does not indicate dehydration.
D. Cool skin: Dehydration usually results in warm, dry skin due to decreased perfusion and sweating.

A. Hyperactive reflexes B. Weak, irregular pulse C. Extreme thirst D. Hyperactive bowel sounds

Correct Answer is B

Explanation

A. Hyperactive reflexes: Hypokalemia typically causes hyporeflexia (reduced reflexes), not hyperactive reflexes.
B. Weak, irregular pulse: Hypokalemia can cause cardiac arrhythmias, leading to a weak and irregular pulse.
C. Extreme thirst: Extreme thirst is more associated with hypernatremia, not hypokalemia.
D. Hyperactive bowel sounds: Hypokalemia generally causes decreased bowel motility, leading to hypoactive bowel sounds.

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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 collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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?

A nurse is caring for a client who is postoperative and has an NG tube that has drained 2,500 mL in the past 6 hr. The nurse should monitor the client for which of the following electrolyte imbalances?

A nurse is preparing to perform a urinary catheterization to obtain a urine specimen for a client. The client tells the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take to alleviate the client's concern?

A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?

A nurse is collecting data from a client who has a calcium level of 8 mg/dL. Which of the following manifestations should the nurse expect?

A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

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?

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?