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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the child in an upright position: This is the correct answer. Sitting upright can help make breathing easier for a child with epiglottitis.
B. Transport the child to radiology for a throat x-ray: While an x-ray can confirm the diagnosis, it should only be done under the supervision of a healthcare provider due to the risk of airway obstruction.
C. Obtain a throat culture: This is not typically done in suspected cases of epiglottitis because it could trigger a spasm and cause airway obstruction.
D. Visualize the epiglottis with a tongue depressor: This should not be done because it can cause airway obstruction and is potentially life-threatening in a child with suspected epiglottitis.
Correct Answer is B
Explanation
A. Osteosarcoma: This is a type of bone cancer that often occurs in teenagers and young adults, but it’s not the most common malignant renal and intra-abdominal tumor of childhood.
B. Wilms’ tumor: This is the correct answer. Wilms’ tumor, also known as nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. It typically occurs in children aged 3 to 4 years.
C. Neuroblastoma: This is a type of cancer that often starts in the adrenal glands, which are on top of the kidneys. It can also develop in nerve tissue along the spine, chest, abdomen, or pelvis. While it is common in infants and young children, it’s not the most common malignant renal and intra-abdominal tumor of childhood.
D. Ewing sarcoma: This is a rare type of cancer that occurs in bones or in the soft tissue around the bones. It’s more common in teenagers and young adults, and it’s not the most common malignant renal and intra-abdominal tumor of childhood.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.