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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hemorrhagic stroke is often associated with a sudden, severe headache, high blood pressure, and neurological symptoms such as seizures and vomiting due to the rupture of a blood vessel in the brain.
B. Thrombotic stroke is typically characterized by the gradual onset of symptoms due to a clot forming in an artery supplying the brain, not usually presenting with sudden severe headache and vomiting.
C. Transient ischemic attack (TIA) presents with temporary neurological symptoms that resolve within 24 hours and does not usually involve seizures, severe headache, or significantly elevated blood pressure.
D. Embolic stroke occurs when a blood clot travels to the brain, leading to sudden onset of symptoms, but it is less commonly associated with the severe headache, vomiting, and hypertension seen in hemorrhagic stroke.
Correct Answer is B
Explanation
A. Assistive personnel are generally not qualified to perform the double-check process for blood transfusion as it requires specialized training and certification.
B. An oncology nurse is a qualified staff member who has the necessary training and experience to correctly verify blood labels and client ID bracelets before transfusion.
C. A phlebotomist's role primarily involves drawing blood, not verifying blood products for transfusion.
D. A senior nursing student may not have the required experience or certification to perform the double-check process for blood transfusion safely.
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