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 D
Explanation
A. Assist the client to a side-lying position: This is not typically necessary for administering nasal decongestant drops. The client can be in an upright position with the head tilted back to allow the drops to flow into the nasal passages.
B. Instruct the client to stay in the same position for 2 min: While it’s beneficial for the client to remain with their head tilted back for a short time after the drops have been administered, a specific time frame of 2 minutes is not typically necessary. The medication will start working regardless.
C. Hold the dropper 2 cm (1 in) above the naris: The dropper should be close to the naris, but not touching it to maintain hygiene and prevent contamination of the dropper. However, holding it 2 cm above may cause the drops to miss the nasal passage and not be as effective.
D. Tell the client to blow her nose gently before the instillation: This is the correct action. Clearing the nasal passages before administering the drops ensures that the medication can reach the affected areas. This is achieved by gently blowing the nose. Therefore, option D is the most appropriate action for the nurse to take.
Correct Answer is B
Explanation
Insert an IV catheter: While this might be necessary later, it’s not the immediate priority. The child’s breathing difficulty is the most urgent concern.
B. Prepare for nasotracheal intubation: This is the correct answer. The child’s severe dyspnea indicates a serious breathing problem. Nasotracheal intubation can help ensure the child’s airway remains open.
C. Administer an antipyretic: While this might help reduce the child’s fever, it won’t address the immediate life-threatening issue, which is the child’s difficulty breathing.
D. Obtain blood culture specimens: This could be helpful in diagnosing the cause of the child’s symptoms, but it’s not the immediate priority. The first concern should be stabilizing the child’s condition.
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