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 B
Explanation
Answer: (B) "I will apply heat."
Rationale:
A) "I will elevate the affected part." Elevating the affected part is an appropriate action for controlling a minor bleeding episode. Elevation helps reduce blood flow to the area, minimizing swelling and bleeding.
B) "I will apply heat." Applying heat is not recommended for managing bleeding episodes in hemophilia. Heat can increase blood flow to the affected area, which may worsen bleeding. Instead, applying ice or a cold compress is preferred as it helps constrict blood vessels and reduce bleeding and swelling.
C) "I will compress the site." Applying compression to the site is a correct method for controlling bleeding. Gentle pressure helps reduce blood flow and promotes clot formation, which is crucial in managing bleeding episodes.
D) "I will have my child rest." Encouraging rest is beneficial for a child with hemophilia during a bleeding episode. Resting helps minimize movement and further injury, which can assist in controlling bleeding and promoting recovery.
Correct Answer is B
Explanation
A. Percuss each lung segment for 15 min: While percussion is a part of chest physiotherapy, it doesn’t typically need to be performed for 15 minutes per lung segment. The duration can vary based on the child’s needs and tolerance.
B. Administer albuterol prior to CPT: This is the correct answer. Albuterol is a bronchodilator that can help open the airways and make the chest physiotherapy more effective.
C. Perform CPT immediately after the child eats: This is not recommended because it can increase the risk of vomiting. It’s usually better to perform CPT before meals or at least 1 hour after meals.
D. Perform vibration during the client’s inspirations: Vibration is typically performed during exhalation, not inspiration, to help loosen and mobilize secretions in the lungs.
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