A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
Pause the enema and give the client pain medication.
Discontinue the enema.
Continue the enema and reassure the client.
Lower the height of the solution bag.
The Correct Answer is D
A. Pause the enema and give the client pain medication. Pain medication is not appropriate for mild cramping caused by an enema.
B. Discontinue the enema. Stopping the enema entirely may not be necessary and could prevent the procedure from being effective.
C. Continue the enema and reassure the client. Continuing the enema without adjustment may cause increased discomfort.
D. Lower the height of the solution bag. Lowering the height of the enema bag can reduce the flow rate, easing cramping and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Muscle hypotonicity: Hypercalcemia can lead to muscle weakness and hypotonicity.
B. Tachycardia: Hypercalcemia more commonly causes bradycardia rather than tachycardia.
C. Positive Chvostek's sign: This is associated with hypocalcemia, not hypercalcemia.
D. Diarrhea: Hypercalcemia typically causes constipation, not diarrhea.
Correct Answer is D
Explanation
A. Assist the client to low Fowler's position. The client should be in at least a semi-Fowler's position (30-45 degrees) to reduce the risk of aspiration, not low Fowler's.
B. Warm the feeding solution to body temperature. Feeding solutions should be administered at room temperature to prevent discomfort or gastrointestinal issues, not warmed to body temperature.
C. Discard any residual gastric contents. Residual gastric contents should be checked to assess tolerance to the previous feeding, but not automatically discarded. Decisions should be based on the volume and the facility's protocol.
D. Test the pH of gastric aspirate. Testing the pH of gastric aspirate helps verify proper tube placement before administering feedings.
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