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 B
Explanation
A. Placing the client into a shower and removing dead tissue is not an escharotomy; it refers to wound care practices.
B. An escharotomy involves making large incisions through the eschar (the thick, dead tissue) to relieve pressure and improve circulation, especially if the burn has caused circumferential constriction.
C. Non-surgical removal of dead tissue is typically done via debridement, not escharotomy.
D. Removing healthy skin for grafting is known as skin grafting, not escharotomy.
Correct Answer is A
Explanation
A. Airway obstruction is the priority because burns to the head, neck, and chest can compromise the airway due to swelling, soot, and edema. Immediate assessment and intervention are critical to ensure the airway remains patent and to prevent respiratory distress.
B. While infection is a significant risk in burn patients, addressing airway concerns takes precedence to prevent immediate life-threatening complications.
C. Paralytic ileus is a concern in burn patients but is less immediate compared to the risk of airway obstruction.
D. Fluid imbalance is crucial in burn management, but ensuring a clear airway is the immediate priority to prevent severe complications such as asphyxia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.