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
A. Apex of the heart: While the apex of the heart is a common site to listen to the heart sounds, it’s not typically used to measure the heart rate in infants.
B. Brachial artery: This is the correct answer. The brachial artery, located on the inside of the upper arm, is commonly used to assess the heart rate in infants.
C. Carotid artery: The carotid artery, located on the neck, is commonly used to assess the heart rate in adults, but it’s not typically used in infants.
D. Radial artery: The radial artery, located on the wrist, is also commonly used to assess the heart rate in adults, but it’s not typically used in infants.
Correct Answer is C
Explanation
A. “I use a suppository every night to have a bowel movement”: This is a common practice for individuals with paralysis to manage bowel movements and prevent constipation.
B. “I do wheelchair exercises while watching TV”: Regular exercise is important for overall health and can help prevent complications such as pressure sores and muscle atrophy.
C. “I only need to catheterize myself twice every day”: This statement indicates a need for further teaching. Individuals with spina bifida who are paralyzed from the waist down typically need to perform intermittent catheterization every 3-4 hours to prevent urinary retention and urinary tract infections.
D. “I carry a water bottle with me because I drink a lot of water”: Staying hydrated is important for overall health and can help prevent urinary tract infections, which are common in individuals who perform intermittent catheterization. Therefore, option C is the statement that indicates a need for further teaching.
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