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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Perform hand hygiene with an alcohol-based agent: Alcohol-based hand sanitizers are not effective against C. difficile spores. Soap and water should be used.
B. Obtain stool cultures from all clients on the nursing unit: Only clients with symptoms should have stool cultures obtained.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Antibiotic therapy should only be started after a confirmed diagnosis, as unnecessary antibiotics can contribute to antibiotic resistance.
D. Place all clients who have manifestations on contact precautions: This helps prevent the spread of C. difficile until lab results confirm the diagnosis.
Correct Answer is D
Explanation
36. A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?
A. Constipation
B. Hyporeflexia
C. Increased appetite
D. Headache
Correct answer:
A. Constipation
• Rationale: Constipation is not a common symptom of hyponatremia (low sodium levels).
B. Hyporeflexia
• Rationale: Hyponatremia can cause neuromuscular symptoms, but hyporeflexia (reduced reflexes) is not typically one of them. Hyperreflexia (increased reflexes) is more common.
C. Increased appetite
• Rationale: Increased appetite is not associated with hyponatremia. Symptoms usually relate to neurological and gastrointestinal systems.
D. Headache
• Rationale: Headache is a common symptom of hyponatremia due to cellular swelling and increased intracranial pressure.
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