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 A

Explanation

A. Feelings of isolation: This is the correct answer. Isotretinoin has been linked to depression and suicidal ideation in some cases. Therefore, any changes in mood, including feelings of isolation, should be reported to the healthcare provider immediately.
B. Itching of skin: While this can be a side effect of isotretinoin, it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.
C. Back pain: This can be a side effect of isotretinoin, but it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.
D. Frequent nosebleeds: This can be a side effect of isotretinoin due to dryness of the nasal passages, but it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.

A. Cranberry juice B. Crushed ice C. Vanilla milkshake D. Orange juice

Correct Answer is D

Explanation

A. Cranberry juice: This is generally safe to consume after a tonsillectomy. It is not acidic and will not irritate the throat.
B. Crushed ice: This can be soothing for the throat after a tonsillectomy and can help reduce swelling.
C. Vanilla milkshake: While dairy products can sometimes cause phlegm to thicken, making it harder to swallow, they are generally considered safe after a tonsillectomy unless the child has a known dairy allergy or intolerance.
D. Orange juice: This is the correct answer. Orange juice is acidic and can irritate the throat after a tonsillectomy, so it should be avoided.

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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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