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 manifestation of gastrointestinal perforation includes severe upper abdominal pain. This can be a significant symptom indicating a potential perforation in the gastrointestinal tract. It is important to note that gastrointestinal perforation is a medical emergency that requires immediate attention and intervention.
Hyperactive bowel sounds: This finding is more commonly associated with conditions like bowel obstruction or gastroenteritis rather than gastrointestinal perforation.
Bradycardia: Bradycardia (slower than normal heart rate) is not a typical manifestation of gastrointestinal perforation. It may be associated with other conditions or factors.
Report of epigastric fullness: Epigastric fullness can be a symptom of various gastrointestinal conditions, including peptic ulcer disease itself. However, it is not a specific manifestation of gastrointestinal perforation.
Correct Answer is B,A,C,D
Explanation
The correct sequence of steps the nurse should take to administer the enema is:
1. Provide for the client's privacy by closing the curtains.
2. Confirm the client's identity by checking her wristband.
3. Assist the client into the Sims position.
4. Insert the tip of the enema tubing into the client's rectum.
Proper infection control measures, preparing the enema solution, monitoring the flow rate, and documenting the procedure are among other important considerations that should be taken into account.
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