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 A
Explanation
Sucralfate is a medication used to treat peptic ulcers by forming a protective coating on the stomach lining. It should be taken on an empty stomach, as food can interfere with its absorption and effectiveness. One hour before breakfast and the evening meal is the correct timing for administering sucralfate, allowing for an empty stomach before meals.
At the time the client takes a proton pump inhibitor: Proton pump inhibitors are a different class of medications used to reduce stomach acid production. It is recommended to administer sucralfate separately, as it works differently and has different administration requirements.
Thirty minutes after breakfast and the evening meal: Administering sucralfate after meals is not ideal, as it may not provide the desired therapeutic effect on an empty stomach.
The time the client takes an antacid: Antacids are also different from sucralfate, and they can interfere with its absorption. It is generally recommended to administer sucralfate separately from antacids.
Correct Answer is ["B","D"]
Explanation
When reinforcing teaching with a client who has a duodenal ulcer and a new prescription for cimetidine, the nurse should include the following instructions:
"Avoid taking the medication at bedtime.": Cimetidine is most effective when taken during waking hours to help control gastric acid secretion. Taking it at bedtime may not provide optimal therapeutic benefits.
"You will need to continue taking this medication for up to 6 weeks.": Cimetidine is often prescribed for the treatment of duodenal ulcers and may require several weeks of continuous use to promote healing. It is important for the client to understand the duration of treatment and the need for adherence to the prescribed regimen.
The following statements are incorrect or not applicable:
"Drinking grapefruit juice while taking cimetidine can lead to toxicity.": Cimetidine does not have a known interaction with grapefruit juice. However, it is always important to consult the healthcare provider or pharmacist about potential drug interactions, including those related to specific foods or beverages.
"Take an antacid 30 minutes prior to taking cimetidine to minimize stomach upset.": Cimetidine is an H2 receptor antagonist that works by reducing stomach acid production. It is not necessary to take an antacid prior to taking cimetidine to minimize stomach upset. However, if the client experiences stomach upset or discomfort, they should consult their healthcare provider for further guidance on managing these symptoms.
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