A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. Which of the following actions should the nurse take?

Discontinue the enema.

Slow the rate of instillation.

Ask the client to hold his breath until the cramping passes.

Pause the enema to administer pain medication to the client.

Answer and Explanation

The Correct Answer is B

A. Discontinue the enema: Mild cramping is a common response during enema administration and does not require stopping the procedure. Discontinuing unnecessarily would prevent the client from receiving the intended therapeutic effect.

B. Slow the rate of instillation: Cramping often occurs when the solution enters the rectum too quickly. Slowing the rate allows the colon to accommodate the fluid more comfortably, reducing discomfort while continuing the enema safely and effectively.

C. Ask the client to hold his breath until the cramping passes: Holding the breath does not relieve rectal cramping and may increase client discomfort or anxiety. Comfort measures should focus on adjusting the procedure rather than altering breathing inappropriately.

D. Pause the enema to administer pain medication to the client: Administering systemic pain medication is unnecessary for mild, transient cramping. Slowing the enema is sufficient to manage discomfort, and pausing for medication would unnecessarily delay treatment.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Mastitis: Mastitis is an infection of the breast tissue, often caused by bacteria entering through a cracked nipple. It presents with localized redness, warmth, tenderness, swelling, and systemic symptoms such as fever and chills. These signs align with the client’s sudden onset of chills and a tender, red area on the breast, indicating an acute infectious process.

B. Engorgement: Engorgement occurs when the breasts are overfilled with milk, leading to generalized swelling, firmness, and mild discomfort. It usually develops gradually rather than suddenly and is not associated with systemic symptoms like chills or fever.

C. Blocked milk duct: A blocked duct can cause localized firmness and tenderness, often forming a small, palpable lump. Unlike mastitis, it typically does not produce systemic symptoms such as chills or fever, and the redness is usually limited to the area over the blockage rather than indicating infection.

D. Thrush: Thrush is a fungal infection caused by Candida species, affecting the nipple or infant’s mouth. It presents with pain during breastfeeding, itching, or burning, and may show white patches on the nipple or tongue. Thrush does not cause localized redness, tenderness, or systemic symptoms such as chills.

A. "Wait 5 minutes between doses." B. "Place 2 tablets under your tongue." C. "You can take up to 4 tablets in 20 minutes." D. "Drink a full glass of water with the medication."

Correct Answer is A

Explanation

A. "Wait 5 minutes between doses.": Sublingual nitroglycerin is taken to relieve acute angina episodes. The recommended protocol is to place one tablet under the tongue and, if pain persists, repeat every 5 minutes as needed, up to a maximum of three doses within 15 minutes. Waiting 5 minutes between doses allows the medication to work while monitoring for resolution of symptoms or adverse effects.

B. "Place 2 tablets under your tongue.": Only one tablet should be taken initially. Taking multiple tablets at once increases the risk of severe hypotension, headache, and dizziness. Proper dosing is critical to both effectiveness and safety.

C. "You can take up to 4 tablets in 20 minutes.": The maximum recommended is three tablets in 15 minutes, not four in 20 minutes. Exceeding this can cause significant hypotension and cardiovascular complications.

D. "Drink a full glass of water with the medication.": Sublingual nitroglycerin should not be swallowed or taken with water because it needs to dissolve under the tongue for rapid absorption into the bloodstream. Drinking water would reduce its effectiveness.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is administering a cleansing enema to a client who reports mild cramping during instillation of the solution. 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 is breastfeeding and reports a sudden onset of chills and a tender, red area on the right breast. The nurse should identify that these manifestations indicate which of the following conditions?

Correct Answer is A

Explanation

A nurse is speaking with a client who called the provider's office to report chest pain and requests clarification about how to take their sublingual nitroglycerin. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse in the emergency department is assisting with the care of a client. For each assessment finding below, click to specify if the finding is consistent with appendicitis, diverticulitis, or celiac disease. Each finding may support more than 1 disease process.

A nurse is preparing to administer medication to a child through an enteral tube. Which of the following actions should the nurse take after administering the medication?

A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching about the aging process with an older adult client. Which of the following Information should the nurse Include?

A nurse is collecting data from a client who received IV morphine for postoperative pain. The nurse should identify that which of the following findings indicates a therapeutic response to the medication?

A nurse is reinforcing teaching with a client who is scheduled for a mammogram. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with the family of a client who is receiving palliative care for terminal cancer. Which of the following guidelines should the nurse emphasize about appropriate pain control measures?

A nurse is preparing to administer amikacin 5 mg/kg IM every 8 hr to a client. The client weighs 70.8 kg. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)