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. Limiting the number of health care workers entering the room helps reduce the risk of infection for immunosuppressed clients, who have weakened immune systems and are more susceptible to infections.
B. For clients with immunosuppression, monitoring the temperature more frequently (e.g., every 4 hours) is important to promptly identify signs of infection.
C. Providing fresh fruit might introduce potential sources of infection; it is safer to provide well-cooked or processed fruits.
D. Inserting an indwelling catheter may increase the risk of infection, and it is generally better to use less invasive methods unless absolutely necessary.

A. Apply wrist and leg restraints to the client. B. Call the family and ask them to stay with the client. C. Administer medication to sedate the client. D. Move the client to a room closer to the nurses' station.

Correct Answer is D

Explanation

A. Applying restraints should be a last resort and only if less restrictive measures have failed. It is also essential to follow legal and ethical guidelines regarding the use of restraints.

B. Calling the family to stay with the client may provide temporary comfort but does not directly address safety concerns or the underlying cause of restlessness and confusion.

C. Sedating the client might not be appropriate without first assessing the cause of the restlessness and confusion. Medications should be used cautiously and based on a thorough evaluation.

D. Moving the client closer to the nurses' station allows for more frequent monitoring and quick intervention if needed, addressing the immediate safety concern of restlessness and confusion. This measure helps ensure the client’s safety while further assessment and intervention are being planned.

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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?

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Correct Answer is A

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