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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Osteosarcoma: This is a type of bone cancer that often occurs in teenagers and young adults, but it’s not the most common malignant renal and intra-abdominal tumor of childhood.
B. Wilms’ tumor: This is the correct answer. Wilms’ tumor, also known as nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. It typically occurs in children aged 3 to 4 years.
C. Neuroblastoma: This is a type of cancer that often starts in the adrenal glands, which are on top of the kidneys. It can also develop in nerve tissue along the spine, chest, abdomen, or pelvis. While it is common in infants and young children, it’s not the most common malignant renal and intra-abdominal tumor of childhood.
D. Ewing sarcoma: This is a rare type of cancer that occurs in bones or in the soft tissue around the bones. It’s more common in teenagers and young adults, and it’s not the most common malignant renal and intra-abdominal tumor of childhood.
Correct Answer is A
Explanation
A. Perform a neurovascular assessment: This is the correct answer. After a cast is applied, it’s crucial to regularly assess the client’s neurovascular status (sensation, movement, temperature, color, and capillary refill) to ensure that the cast is not too tight and that circulation is not compromised.
B. Provide reassurance to the client and parents: While this is important, the immediate priority is to ensure the client’s physical well-being.
C. Apply an ice pack to the casted leg: This can help reduce swelling and pain, but it’s not the immediate priority. The nurse first needs to ensure that the cast is not compromising circulation or nerve function.
D. Explain the discharge instructions to the client and parents: This is typically done later, closer to the time of discharge. The immediate priority is to assess the client’s physical condition.
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