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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Respiratory: While respiratory symptoms can occur in Kawasaki disease, they are not the primary concern.
B. Gastrointestinal: Gastrointestinal symptoms can occur in Kawasaki disease, but they are not the primary concern.
C. Integumentary: Although Kawasaki disease can cause symptoms such as a rash and peeling skin, these are not the primary concerns.
D. Cardiovascular: This is the correct answer. Kawasaki disease can lead to serious complications involving the heart, such as coronary artery aneurysms. Therefore, monitoring the cardiovascular system is crucial in managing this condition.
Correct Answer is C
Explanation
A. “Place your child in a sitting position with her head tilted back.”: This is not recommended because it can cause the blood to flow down the back of the throat, which can lead to gagging or choking.
B. “Apply ice at the base of the nose for 5 min and then check for bleeding.”: While applying ice can help constrict the blood vessels and slow the bleeding, it’s not the most effective initial step in managing a nosebleed.
C. “Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes.”: This is the correct answer. Tilting the head forward prevents the blood from flowing down the back of the throat, and applying pressure to the nostrils can help stop the bleeding.
D. “Place your child in a supine position with a pillow under her back.”: Lying down can increase blood pressure in the veins of the nose, which can make the nosebleed worse. It’s better to keep the head elevated.
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