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. Avoid gas-producing foods: Avoiding gas-producing foods may reduce bloating but does not directly address constipation.
B. Add fluid and fiber to the diet. Increasing fluid and fiber intake helps to soften stool and promote regular bowel movements.
C. Promote active range-of-motion activities: While physical activity can help with bowel movements, active range-of-motion activities alone are not sufficient to address constipation.
D. Request that the provider prescribe a stool softener: This may be helpful but is usually considered after dietary measures have been attempted.

A. Observe the client. B. Complete an incident report. C. Notify the nurse manager. D. Call the client's provider.

Correct Answer is A

Explanation

A. Observe the client. The first priority is to monitor the client for any adverse reactions or side effects from the wrong medication.
B. Complete an incident report. While important, the incident report is not the first action to take.
C. Notify the nurse manager. Informing the nurse manager is necessary, but not the immediate first step.
D. Call the client's provider. Notifying the provider is also important but observing the client for any immediate effects takes precedence.

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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

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Explanation

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Correct Answer is A

Explanation

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