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 ["100"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula: Flow rate (gtt/min) = (Volume to be infused in mL) x (Drop factor) / (Time in minutes) In this case, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.

Flow rate (gtt/min) = (100 mL) x (60 gtt/mL) / (60 min)

Canceling out the mL and min units, the formula becomes:

Flow rate (gtt/min) = 100 x 60 / 60

Flow rate (gtt/min) = 100

Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.

A. "Daily bowel movements are necessary for good intestinal health.” B. "Chronic use of laxatives can lead to a tear in the rectal mucosa" C. "Decrease your intake of high-fiber foods." D. "Excessive laxative use can cause an electrolyte imbalance.”

Correct Answer is D

Explanation

Bisacodyl is a stimulant laxative commonly used to treat constipation. However, it is important to educate the client about the potential risks associated with chronic laxative use. The statement regarding electrolyte imbalance is important because excessive or prolonged use of laxatives can lead to electrolyte disturbances, such as low potassium levels (hypokalemia), which can have adverse effects on various body functions.

"Daily bowel movements are necessary for good intestinal health": While regular bowel movements are generally desirable, stating that daily bowel movements are necessary for good intestinal health is an overgeneralization. Bowel movement frequency can vary among individuals, and it is important to consider other factors such as diet, hydration, and overall health.

"Chronic use of laxatives can lead to a tear in the rectal mucosa": While chronic use of laxatives can lead to complications such as dependence and potential damage to the digestive system, specifically mentioning a tear in the rectal mucosa (rectal mucosal injury) is not the most commonly associated concern.

"Decrease your intake of high-fiber foods": It is generally recommended to increase fiber intake for individuals with constipation. Decreasing high-fiber foods would counteract the benefits of dietary fiber in promoting regular bowel movements and alleviating constipation.

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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 preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/ml. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

Correct Answer is ["100"]

Explanation

A nurse is reinforcing teaching with a client who reports taking bisacodyl daily. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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