A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

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

Allow the client to expel some fluid before continuing.

Encourage the client to bear down.

Lower the height of the solution container.

Answer and Explanation

The Correct Answer is D

A. Stop the enema and document that the client did not tolerate the procedure: This action might be necessary in some cases, but it’s not the first action to take. The nurse should first try to alleviate the client’s discomfort.

B. Allow the client to expel some fluid before continuing: This action could potentially relieve some discomfort, but it’s not the most effective initial response. The cramping is likely due to the speed at which the fluid is entering, not the amount of fluid already administered.

C. Encourage the client to bear down: This action is not typically recommended during an enema administration as it could increase discomfort.

D. Lower the height of the solution container: This is the correct action. Lowering the height of the solution container will decrease the speed at which the fluid is entering the client’s rectum, which can help alleviate cramping and discomfort. Therefore, option D is the most appropriate action for the nurse to take.

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Correct Answer is D

Explanation

A. “Burp your baby more frequently during feedings”: While burping can help with minor feeding issues, it’s unlikely to resolve the issue of projectile vomiting after eating.

B. “Try switching to a different formula”: While this might be an option in some cases, it’s not the first step to take. Projectile vomiting can be a sign of a more serious condition, such as pyloric stenosis, which needs medical attention.

C. “Give your infant an oral rehydration solution”: While rehydration is important, especially if the baby is vomiting, it doesn’t address the underlying issue causing the vomiting.

D. “Bring your baby in to the clinic today”: This is the correct action. Projectile vomiting in an infant, especially when combined with increased hunger, is a concern and should be evaluated by a healthcare professional as soon as possible

A. Administer 0.9% sodium chloride IV solution. B. Initiate IV antibiotics. C. Place the child on droplet precautions. D. Assist with obtaining an x-ray of the child's neck.

Correct Answer is C

Explanation

A. Administer 0.9% sodium chloride IV solution: While hydration is important, it’s not the first step in managing a child with suspected epiglottitis.

B. Initiate IV antibiotics: Antibiotics are typically used in the treatment of epiglottitis, but they are not the first step. The first step should be to prevent the spread of the infection.

C. Place the child on droplet precautions: This is the correct answer. Epiglottitis is a potentially life-threatening condition caused by infection. Droplet precautions can help prevent the spread of the infection to others.

D. Assist with obtaining an x-ray of the child’s neck: While an x-ray can help confirm the diagnosis of epiglottitis, it’s not the first step. The first step should be to prevent the spread of the infection.

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A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediate eating. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states h abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?

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