A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container.

Stop the enema and document that the client did not tolerate the procedure.

Encourage the client to bear down

Allow the client to expel some fluid before continuing

Answer and Explanation

The Correct Answer is D

When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.

The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:

Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.

Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.

Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.

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Correct Answer is ["14"]

Explanation

To calculate the infusion rate in drops per minute (gtt/min), we can use the following formula: Infusion rate (gtt/min) = (Volume to be infused (ml) * Drop factor) / Time (min) Given:

Volume to be infused: 1000 ml

Drop factor: 10 gtt/ml

Time: 12 hr

First, we need to convert the time from hours to minutes:

12 hr * 60 min/hr = 720 min

Now, we can calculate the infusion rate:

Infusion rate (gtt/min) = (1000 ml * 10 gtt/ml) / 720 min

Simplifying the equation:

Infusion rate (gtt/min) = 10000 gtt / 720 min

Dividing both sides:

Infusion rate (gtt/min) ≈ 13.89 gtt/min

Rounding the answer to the nearest whole number, the nurse should set the manual IV infusion to deliver approximately 14 gtt/min.

A. "I feel so much better after eating." B. "The pain is worse after I eat a meal high in fat." C. "The pain radiates down to my lower back." D. "My pain is relieved by having a bowel movement."

Correct Answer is B

Explanation

A. "I feel so much better after eating."This is most consistent with a duodenal ulcer, where pain is relieved by food (but often returns 2–3 hours later). Gastric ulcers, on the other hand, may worsen with eating.

B. "The pain is worse after I eat a meal high in fat."Fatty food intolerance and postprandial pain are more characteristic of gallbladder disease (cholelithiasis/cholecystitis), not PUD.

C. "The pain radiates down to my lower back."Pain radiating to the back is more typical of pancreatitis, not PUD.

D. "My pain is relieved by having a bowel movement."Relief of abdominal pain with a bowel movement suggests irritable bowel syndrome (IBS), not PUD.

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A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["14"]

Explanation

A nurse is collecting data from a client in the health clinic who is reporting epigastric pain. Which of the following statements made by the client should the nurse identify as being consistent with peptic ulcer disease?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has been taking esomeprazole for several months. Which of the following client statements should the nurse identify as indicating effectiveness of the medication?

A nurse is reinforcing teaching a client who has peptic ulcer disease and is starting therapy with sucralfate. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a client who has been taking omeprazole for the past 4 weeks. The nurse determines that the medication is effective when the client reports relief from which of the following symptoms?

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A nurse is reinforcing teaching for a client who has a duodenal ulcer and a new prescription for sucralfate. The client asks the nurse how sucralfate works. Which of the following statements should the nurse make?

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the client's feces?