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 B

Explanation

A. Induce vomiting with syrup of ipecac: This is not recommended because it can lead to further complications, such as aspiration pneumonia.
B. Perform gastric lavage with activated charcoal: This is the correct answer. Activated charcoal can bind to acetylsalicylic acid (commonly known as aspirin) in the stomach and intestines to prevent the body from absorbing it, which can help to reduce the severity of an overdose.
C. Initiate chelation therapy with deferoxamine: This is used to treat iron poisoning, not acetylsalicylic acid overdose.
D. Administer N-acetylcysteine: This is used as an antidote for acetaminophen (Tylenol) overdose, not for acetylsalicylic acid.

A. Apex of the heart B. Brachial artery C. Carotid artery D. Radial artery

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.

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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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