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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Tetany: A calcium level of 8 mg/dL is below the normal range (8.5-10.5 mg/dL) and can cause tetany, which includes muscle cramps, spasms, and positive signs like Chvostek and Trousseau signs.
B. Constipation: Constipation is more commonly associated with hypercalcemia, not hypocalcemia.
C. Negative Chvostek sign: A positive Chvostek sign is expected in hypocalcemia, indicating neuromuscular irritability.
D. Elevated blood pressure: Elevated blood pressure is not specifically associated with hypocalcemia.

A. Explain the procedure to the client. B. Obtain assistance so the client does not become resistant to the procedure. C. Gather the equipment necessary before starting the procedure. D. Close the door and cover the client during the procedure.

Correct Answer is D

Explanation

A. Explain the procedure to the client: While explaining the procedure is important, it does not directly address the client's privacy concerns.
B. Obtain assistance so the client does not become resistant to the procedure: Obtaining assistance may help with the procedure but does not address the client's privacy concerns and might increase their anxiety.
C. Gather the equipment necessary before starting the procedure: Gathering equipment is important for preparedness but does not directly address privacy concerns.
D. Close the door and cover the client during the procedure: Closing the door and covering the client directly addresses privacy concerns and helps the client feel more comfortable and secure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a calcium level of 8 mg/dL. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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