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 B

Explanation

A. Increased blood pressure: Hypovolemia typically causes a decrease in blood pressure, not an increase.
B. Thready pulse: A thready pulse is a common sign of hypovolemia due to decreased blood volume.
C. Dyspnea: While dyspnea can occur, it is not as specific as a thready pulse for hypovolemia.
D. Decreased heart rate: Hypovolemia usually causes an increased heart rate as the body tries to compensate for low blood volume.

A. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. B. Locate the center of the arm between the elbow and the shoulder. C. Find the center of the anterior aspect of the thigh. D. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.

Correct Answer is A

Explanation

A. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. This is the correct method to locate the deltoid muscle for an intramuscular injection.
B. Locate the center of the arm between the elbow and the shoulder. This method does not accurately locate the deltoid muscle and may lead to incorrect injection placement.
C. Find the center of the anterior aspect of the thigh: This method locates the vastus lateralis muscle, not the deltoid muscle.
D. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle.: This method locates the vastus lateralis muscle, not the deltoid muscle.

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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 sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Correct Answer is B

Explanation

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Correct Answer is A

Explanation

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