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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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is ["240"]
Explanation
To calculate the total fluid intake, we need to convert all measurements to the same unit. In this case, we’ll convert everything to milliliters (mL).
1 cup = 240 mL 1 ounce (oz) = 30 mL
So, the child’s fluid intake is:
Juice: 1/2 cup = 120 mL
Gelatin: 3 oz = 90 mL
Ginger ale: 1 oz = 30 mL
Adding these together gives:
120 mL (juice) + 90 mL (gelatin) + 30 mL (ginger ale) = 240 mL
Therefore, the nurse should record the child’s fluid intake as 240 mL.
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