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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Elevating the head of the bed can help reduce the symptoms of GERD during sleep. By elevating the head, gravity can help prevent stomach acid from flowing back into the esophagus, reducing the occurrence of reflux.
The other statements do not demonstrate an understanding of the teaching: "I will sleep on my stomach with my head flat": Sleeping on the stomach can actually worsen the symptoms of GERD as it can increase the likelihood of stomach acid flowing back into the esophagus. It is generally recommended to sleep on the left side or back to minimize reflux.
"I will have a snack 1 hour before going to bed": Consuming a snack close to bedtime can increase the likelihood of reflux during sleep. It is generally recommended to avoid eating at least 2 to 3 hours before lying down to minimize reflux symptoms.
"I can have 6 ounces of alcohol before bed, to help me sleep": Alcohol can relax the lower esophageal sphincter (LES) and increase the risk of reflux. It is best to avoid alcohol before bedtime, especially for individuals with GERD.
Correct Answer is B
Explanation
Atenolol is a beta-blocker medication commonly used to treat conditions such as hypertension (high blood pressure) and certain heart rhythm disorders. One of the intended effects of atenolol is to lower the heart rate by blocking the action of adrenaline on beta receptors in the heart. However, this can sometimes result in bradycardia, which refers to a heart rate that is slower than the normal range.
Hypokalemia, or low potassium levels, is not directly caused by atenolol but can be an indirect effect. Beta-blockers like atenolol can potentially interfere with the normal release of insulin and contribute to increased urinary excretion of potassium. Therefore, it's important to monitor potassium levels in clients taking atenolol, as low potassium levels can have adverse effects on various body systems.
Anemia and neutropenia are not typically associated with the use of atenolol. Anemia refers to a decrease in the number of red blood cells or a decrease in the amount of hemoglobin, which carries oxygen to the body tissues. Neutropenia refers to a decrease in the number of neutrophils, which are a type of white blood cell involved in fighting infection.
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