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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Regular use of a laxative: Regular use of laxatives is not recommended during pregnancy as it can lead to dependence and potentially harm the mother and fetus.
B. Maintenance of good posture: While good posture is beneficial, it does not specifically address constipation.
C. Regular use of glycerine suppositories: This should not be the first line of treatment; dietary changes are preferable.
D. Increased cellulose and fluid in the diet: Increasing dietary fiber (cellulose) and fluid intake is the safest and most effective way to manage constipation during pregnancy.
Correct Answer is A
Explanation
A. Chvostek's sign: Chvostek's sign is a facial muscle spasm elicited by tapping the facial nerve and is indicative of hypocalcemia.
B. Brudzinski's sign: Brudzinski's sign is associated with meningitis, not hypocalcemia.
C. Cullen's sign: Cullen's sign indicates intra-abdominal bleeding, not hypocalcemia.
D. Kernig's sign: Kernig's sign is associated with meningitis, not hypocalcemia.
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