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 B
Explanation
A. Use sterile water to inflate the balloon: There is no balloon in a straight catheterization; this applies to indwelling catheters.
B. Use a sterile specimen container: A sterile specimen container ensures that the sample is not contaminated.
C. Instruct the client to clean from front to back with an antiseptic solution: This is relevant to midstream urine collection but not for straight catheterization.
D. Collect urine from the catheter's port. In straight catheterization, urine is collected directly as it exits the catheter, not from a port.
Correct Answer is D
Explanation
A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.
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