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
When reinforcing teaching about cimetidine with a client who has peptic ulcer disease, the nurse should include the following information:
"Wait at least 1 hour after taking the medication before taking an antacid.": Cimetidine is a histamine-2 receptor antagonist that reduces stomach acid production. Taking an antacid too close in time to cimetidine may decrease its effectiveness as antacids can interfere with its absorption. The nurse should advise the client to follow the healthcare provider's instructions regarding the timing and administration of cimetidine and antacids.
The following statements are incorrect or not applicable:
"Expect breast tenderness while taking this medication.": Breast tenderness is not a common side effect of cimetidine. If the client experiences any unusual symptoms or side effects while taking the medication, they should consult their healthcare provider for further evaluation.
"Take this medication on an empty stomach.": To reduce stomach upset, this medication should be taken with food or milk
"Take ibuprofen for occasional aches and pains.": Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal complications, including ulcers. In individuals with peptic ulcer disease, it is generally recommended to avoid NSAIDs unless specifically prescribed by a healthcare provider. The nurse should emphasize the importance of discussing any pain management strategies or medications with the healthcare provider before use.
Correct Answer is ["C","D"]
Explanation
When reinforcing teaching with a client who has a duodenal ulcer and a new prescription for sucralfate, the nurse should include the following instructions:
"Take the medication on an empty stomach.": Sucralfate is most effective when taken on an empty stomach, usually 1 hour before meals and at bedtime. Taking it with food or other medications may reduce its effectiveness.
"Remain upright for 30 minutes after taking this medication.": To enhance the efficacy of sucralfate, it is important to remain upright for at least 30 minutes after taking the medication. This helps to prevent the medication from being washed away by stomach acid and allows it to form a protective coating over the ulcer.
The following statements are incorrect or not applicable:
"Stop taking this medication if you develop constipation.": Constipation is a common side effect of sucralfate. However, abruptly stopping the medication is not necessary if constipation occurs. The nurse should instruct the client to increase fluid intake, consume a high-fiber diet, and discuss any concerns with the healthcare provider. If constipation becomes severe or persists, the healthcare provider can provide further guidance on managing this side effect.
"Take an antacid at the same time you take this medication.": Sucralfate can interact with antacids and other medications, reducing its effectiveness. It is recommended to take sucralfate at least 2 hours before or after taking antacids or other medications to avoid interference with its absorption.
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