A preoperative nurse is caring for a client who is being prepped for emergency surgery related to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?

Choice A Reason:

Encouraging the client to bear down is not an appropriate response to abdominal cramps during an enema. Bearing down can increase discomfort and does not address the underlying cause of the cramps.

Choice B Reason:

Stopping the enema and documenting that the client did not tolerate the procedure is not the best initial action. While it is important to document the client’s response, there are other steps that can be taken to alleviate the discomfort before stopping the procedure entirely.

Choice C Reason:

This is the correct answer. Lowering the height of the solution container will reduce the flow rate of the enema solution, which can help alleviate abdominal cramps. A slower flow rate is less likely to cause cramping and discomfort.

Choice D Reason:

Allowing the client to expel some fluid before continuing can help relieve discomfort, but it is not the most immediate or effective action. Adjusting the flow rate by lowering the height of the solution container is a more direct way to address the issue.

Choice A Reason:

Contact precautions are recommended for patients with MRSA to prevent the spread of the bacteria. This includes measures such as placing the patient in a single room, using personal protective equipment (PPE) like gowns and gloves, and ensuring proper hand hygiene. These precautions help to minimize the risk of transmission through direct or indirect contact with the patient or their environment.

Choice B Reason:

Protective precautions, also known as reverse isolation, are used to protect immunocompromised patients from infections. This is not applicable for MRSA patients, as the goal is to prevent the spread of MRSA to others, not to protect the patient from external infections.

Choice C Reason:

Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis or measles. MRSA is not transmitted through airborne particles, so this type of precaution is not appropriate.

Choice D Reason:

Droplet precautions are used for diseases that are spread through large respiratory droplets, such as influenza or pertussis. MRSA is primarily spread through direct contact, not through respiratory droplets, making droplet precautions unnecessary.