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?
Lower the height of the solution container.
Stop the enema and document that the client did not tolerate the procedure.
Encourage the client to bear down
Allow the client to expel some fluid before continuing
The Correct Answer is D
When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.
The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:
Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.
Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.
Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement is incorrect and requires correction because it suggests starting the flow of urine before positioning the collection container, which can result in contamination of the specimen. The correct procedure for collecting a midstream urine specimen involves the following steps:
1. Provide the client with a clean urine specimen container.
2. Instruct the client to cleanse the genital area using a provided towelette or antiseptic wipes, wiping from front to back.
3. Instruct the client to start urinating into the toilet or bedpan.
4. As the urine stream continues, the client should pass the collection container into the stream to collect the midstream specimen.
5. Once an adequate amount of urine has been collected (as per the laboratory's instructions), the client should remove the container from the stream of urine. 6. The client can then complete urinating into the toilet or bedpan.
The other statements made by the newly licensed nurse are correct:
"Use the provided towelette to cleanse the area by moving in a back-and-forth motion": This statement correctly instructs the client to cleanse the genital area before collecting the urine specimen.
"It will be easier to use your nondominant hand to spread the labia": This statement is correct as it suggests using the nondominant hand to facilitate the collection process.
"Remove the specimen container before stopping the stream of urine": This statement is correct as it indicates that the container should be removed before completing urination.
Correct Answer is B
Explanation
Sucralfate is a medication commonly used in the treatment of peptic ulcer disease. It works by forming a protective barrier over the ulcer site, providing a physical barrier against gastric acid, and promoting the healing process. When teaching a client about sucralfate, it is important to provide instructions regarding its proper administration.
One of the key instructions is to take sucralfate 1 hour before meals. This timing allows the medication to form a protective coating in the stomach before food is ingested. Taking sucralfate on an empty stomach enhances its effectiveness in protecting the ulcer and promoting healing.
"Take the medication with an antacid" - Sucralfate should not be taken with an antacid. Antacids can interfere with the protective mechanism of sucralfate by neutralizing stomach acid, which is necessary for sucralfate to bind and form a protective coating. It is recommended to wait at least 30 minutes to 1 hour after taking sucralfate before taking an antacid.
"Take as needed for pain relief" - Sucralfate is not typically used for immediate pain relief in peptic ulcer disease. It is primarily used for its protective and healing properties. Pain relief is
usually addressed with other medications, such as antacids, acid-reducing medications, or pain medications as prescribed by a healthcare provider.
"Store the medication in the refrigerator" - Sucralfate does not require refrigeration. It should be stored at room temperature, away from excessive heat or moisture, as per the specific instructions provided by the manufacturer or healthcare provider.
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