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 C

Explanation

A. Administer 0.9% sodium chloride IV solution: While hydration is important, it’s not the first step in managing a child with suspected epiglottitis.

B. Initiate IV antibiotics: Antibiotics are typically used in the treatment of epiglottitis, but they are not the first step. The first step should be to prevent the spread of the infection.

C. Place the child on droplet precautions: This is the correct answer. Epiglottitis is a potentially life-threatening condition caused by infection. Droplet precautions can help prevent the spread of the infection to others.

D. Assist with obtaining an x-ray of the child’s neck: While an x-ray can help confirm the diagnosis of epiglottitis, it’s not the first step. The first step should be to prevent the spread of the infection.

A. Whooping cough B. Chickenpox C. Fifth disease D. Mumps

Correct Answer is A

Explanation

A. Whooping cough: This is the correct answer. Pertussis is commonly known as whooping cough.
B. Chickenpox: This is caused by the varicella-zoster virus, not pertussis.
C. Fifth disease: This is caused by parvovirus B19, not pertussis.
D. Mumps: This is caused by the mumps virus, not pertussis.

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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

Naxlex Comprehensive Predictor Exams

A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The respond with which of the following common names?

Correct Answer is A

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