nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container.

Encourage the client to bear down.

Allow the client to expel some fluid before continuing.

Stop the enema and document that the client did not tolerate the procedure.

Answer and Explanation

The Correct Answer is A

A. Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.

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Correct Answer is A

Explanation

A. Pain management is crucial after amputation, and the client should be informed that postoperative pain may gradually decrease, though some level of discomfort can persist.
B. A tingling sensation is not always expected, and the client should be prepared for a range of sensations postoperatively, including phantom pain.
C. Phantom pain is a real phenomenon experienced by many individuals following an amputation; it is not purely psychological.
D. Pain management strategies should be discussed, and the client should be aware that pain may not disappear immediately and may require ongoing management.

A. Urine output B. Oxygen saturation C. Weight D. Temperature E. Blood pressure F. Breath sounds

Correct Answer is ["A","B","C","F"]

Explanation

A. Urine output: A decrease in urine output from 480 mL/8 hr to 320 mL/8 hr indicates reduced renal perfusion or worsening heart failure. This finding suggests potential fluid retention or impaired kidney function, requiring further investigation and action.

B. Oxygen saturation: A drop in oxygen saturation from 95% to 88% indicates worsening oxygenation and potential respiratory distress or fluid overload. This finding necessitates further assessment and possible intervention to manage the client's respiratory status.

C. Weight: An increase in weight from 80 kg to 82.1 kg suggests fluid retention, which is common in heart failure. This weight gain indicates worsening fluid balance and may require adjustment in treatment to address fluid overload.

F. Breath sounds: The presence of scattered crackles on Day 4 suggests pulmonary congestion or fluid accumulation, which is concerning in heart failure. This finding indicates a worsening of the client’s condition and requires further evaluation and management.

Explanation of Incorrect Options:

D. Temperature: The temperature has slightly decreased but is still within a normal range. This finding does not require immediate further action.

E. Blood pressure: Although there is a change in blood pressure from 108/50 mm Hg to 138/80 mm Hg, this increase is not as critical as the other findings. It is important but less urgent in this context compared to the issues with oxygen saturation, urine output, weight, and breath sounds.

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nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having 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 caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?

Correct Answer is A

Explanation

A nurse is caring for a client who has heart failure. Exhibits A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action? (Select all that apply.)

Correct Answer is ["A","B","C","F"]

Explanation

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