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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is D
Explanation
A. “My child will take the enzymes following meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not after, to help with the digestion of food.
B. “My child will take the enzymes 2 hours before meals.”: This is incorrect. Pancreatic enzymes should be taken with meals, not before, to help with the digestion of food.
C. “My child will take the enzymes to improve her metabolism.”: While pancreatic enzymes do aid in digestion, which is a part of metabolism, this statement is not specific enough to indicate a correct understanding of the purpose of the enzymes.
D. “My child will take the enzymes to help digest the fat in foods.”: This is the correct answer. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food, aiding in their digestion and absorption in the intestines. This is particularly important in conditions like cystic fibrosis, where the pancreas does not produce enough of these enzymes naturally.
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