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 B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

A. Perform neurovascular checks of the extremities. B. Direct the client to perform exercises of the ankle and toes. C. Instruct the client on use of crutches. D. Medicate the client for pain.

Correct Answer is A

Explanation

A. Performing neurovascular checks of the extremities is critical to detect signs of complications such as impaired circulation or nerve damage, which can occur after orthopedic surgery. This assessment is essential for early identification of potential issues.

B. While performing exercises of the ankle and toes is important for preventing complications like deep vein thrombosis, it is secondary to ensuring neurovascular integrity.

C. Instructing the client on the use of crutches is necessary for mobility and safety, but it follows the priority of monitoring for neurovascular complications.

D. Medicating the client for pain is important for comfort, but addressing potential neurovascular issues is a higher priority in the immediate postoperative period to prevent serious complications.

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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

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