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

TB medications are usually required for 6 to 9 months, not for the rest of the client’s life. The treatment duration is designed to ensure complete eradication of the bacteria.
B. A typical course of antitubercular medication involves 6 to 9 months of consistent use to fully treat the infection and prevent resistance.
C. The Mantoux test is used for screening and does not determine the duration of treatment. Medication should be continued as prescribed by the healthcare provider.
D. While family members may need to be screened and potentially treated if exposed, they do not routinely take medications solely to prevent infection unless specifically prescribed.

A. Suction the nostril. B. Ask the client to blow his nose. C. Notify the physician. D. Test the drainage for glucose.

Correct Answer is D

Explanation

A. Suctioning the nostril is not appropriate as it could exacerbate potential cerebrospinal fluid (CSF) leakage or cause further injury.

B. Asking the client to blow their nose could increase intracranial pressure and potentially worsen a skull fracture or CSF leak.

C. While notifying the physician is important, the initial step should be to determine whether the clear drainage is CSF, which has specific implications.

D. Testing the drainage for glucose is crucial because a positive glucose test indicates that the fluid is likely CSF, which can signal a skull fracture and possible brain injury. This finding requires immediate medical evaluation to manage potential complications like infections or worsening of the fracture.

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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 instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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