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 A

Explanation

Elevating the head of the bed can help reduce the symptoms of GERD during sleep. By elevating the head, gravity can help prevent stomach acid from flowing back into the esophagus, reducing the occurrence of reflux.

The other statements do not demonstrate an understanding of the teaching: "I will sleep on my stomach with my head flat": Sleeping on the stomach can actually worsen the symptoms of GERD as it can increase the likelihood of stomach acid flowing back into the esophagus. It is generally recommended to sleep on the left side or back to minimize reflux.

"I will have a snack 1 hour before going to bed": Consuming a snack close to bedtime can increase the likelihood of reflux during sleep. It is generally recommended to avoid eating at least 2 to 3 hours before lying down to minimize reflux symptoms.

"I can have 6 ounces of alcohol before bed, to help me sleep": Alcohol can relax the lower esophageal sphincter (LES) and increase the risk of reflux. It is best to avoid alcohol before bedtime, especially for individuals with GERD.

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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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 reinforcing teaching with a client who has gastroesophageal reflux disease (GERD) about minimizing the effects of reflux during sleep. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

Correct Answer is ["13"]

Explanation

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