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
The purpose of the stool guaiac test, also known as the fecal occult blood test (FOBT), is to identify the presence of hidden or occult blood in the stool. This test is commonly performed to screen for gastrointestinal bleeding, which can indicate various conditions such as colorectal cancer, ulcers, polyps, or other sources of bleeding in the digestive tract.
The other options mentioned are not specifically detected by the stool guaiac test:
Parasites: The stool guaiac test does not directly detect parasites in the feces. Parasite testing requires a different type of analysis, such as microscopic examination or specialized laboratory tests.
Bacteria: The stool guaiac test does not specifically detect bacteria in the feces. If a bacterial infection is suspected, other diagnostic tests such as stool culture or polymerase chain reaction (PCR) may be ordered.
Fat: The stool guaiac test is not designed to detect fat in the feces. If there is a concern about fat malabsorption, other tests such as fecal fat analysis or Sudan stain may be used.
Correct Answer is ["13"]
Explanation
To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:
Volume to be infused: 1,200 ml
Drop factor: 15 gtt/ml
Time: 24 hr
First, we need to convert the time from hours to minutes:
24 hr * 60 min/hr = 1,440 min
Now, we can calculate the infusion rate:
Infusion rate (gtt/min) = (1,200 ml * 15 gtt/ml) / 1,440 min
Simplifying the equation:
Infusion rate (gtt/min) = 18,000 gtt / 1,440 min
Dividing both sides:
Infusion rate (gtt/min) ≈ 12.5 gtt/min
Rounding the answer to the nearest whole number, the nurse should set the manual IV infusion to deliver approximately 13 gtt/min.
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