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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Esomeprazole is a proton pump inhibitor (PPI) medication commonly used to reduce stomach acid production. It is prescribed for conditions such as gastroesophageal reflux disease (GERD) and stomach ulcers. One of the primary goals of esomeprazole is to alleviate stomach pain and discomfort associated with excessive stomach acid.

The other statements mentioned are not directly related to the effectiveness of esomeprazole: "My feet are no longer sore and itchy": Sore and itchy feet are not typical symptoms relieved by esomeprazole. This statement does not indicate the medication's effectiveness.

"I can move my joints more easily": Improved joint mobility is not a direct effect of esomeprazole. This statement does not relate to the medication's purpose.

"My bowel movements have increased in frequency and are much softer": Esomeprazole primarily affects stomach acid production and is not directly related to bowel movements. This statement is not indicative of the medication's effectiveness.

A. Perform hand hygiene. B. Place the sterile package on the work surface. C. Open the outermost flap of the package away from the body. D. Open the side flaps of the package. E. Open the innermost flap of the package toward the body. F. Use the inner surface of the package as a sterile field.

Correct Answer is A,B,C,D,E,F

Explanation

To prepare a sterile field for the insertion of a urinary catheter, the nurse should follow the sequence of actions in the following order:

1. Perform hand hygiene.

2. Place the sterile package on the work surface.

3. Open the outermost flap of the package away from the body.

4. Open the side flaps of the package.

5. Open the innermost flap of the package toward the body.

6. Use the inner surface of the package as a sterile field.

Following this sequence ensures that the nurse maintains proper hand hygiene, prepares the sterile package, and opens it in a way that maintains sterility. Opening the flaps in the correct order helps create a sterile field within the package, which can be used for the insertion of the urinary catheter.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has been taking esomeprazole for several months. Which of the following client statements should the nurse identify as indicating effectiveness of the medication?

Correct Answer is D

Explanation

A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E,F

Explanation

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