A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Stop the enema and document that the client did not tolerate the procedure.

Allow the client to expel some fluid before continuing.

Encourage the client to bear down.

Lower the height of the solution container.

Answer and Explanation

The Correct Answer is D

A. Stop the enema and document that the client did not tolerate the procedure: This action might be necessary in some cases, but it’s not the first action to take. The nurse should first try to alleviate the client’s discomfort.

B. Allow the client to expel some fluid before continuing: This action could potentially relieve some discomfort, but it’s not the most effective initial response. The cramping is likely due to the speed at which the fluid is entering, not the amount of fluid already administered.

C. Encourage the client to bear down: This action is not typically recommended during an enema administration as it could increase discomfort.

D. Lower the height of the solution container: This is the correct action. Lowering the height of the solution container will decrease the speed at which the fluid is entering the client’s rectum, which can help alleviate cramping and discomfort. Therefore, option D is the most appropriate action for the nurse to take.

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Correct Answer is A

Explanation

A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.

A. Influenza, live attenuated (LAIV) B. Haemophilus influenza type b (Hib) C. Hepatitis B (HepB) D. Inactivated poliovirus (IPV)

Correct Answer is A

Explanation

A. Influenza, live attenuated (LAIV): This is the correct answer. The production of this vaccine involves the use of chicken eggs, and it may contain traces of egg protein. Therefore, it should be avoided in individuals with a severe egg allergy.
B. Haemophilus influenza type b (Hib): This vaccine is not contraindicated for individuals with an egg allergy as it does not contain egg protein.
C. Hepatitis B (HepB): This vaccine is safe for individuals with an egg allergy as it does not contain egg protein.
D. Inactivated poliovirus (IPV): This vaccine is not contraindicated for individuals with an egg allergy as it does not contain egg protein.

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A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Nursing Test Bank

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