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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Free Nursing Study Resources

Correct Answer is A

Explanation

Pruritus of the scalp: This is the correct answer. Pruritus, or itching, of the scalp is a common symptom of pediculosis capitis, also known as head lice.
B. Blisters on the scalp: While blisters can occur with various scalp conditions, they are not typically associated with pediculosis capitis.
C. Bald patches on the scalp: Bald patches can be a sign of conditions like alopecia areata or tinea capitis, but they are not typically associated with pediculosis capitis.
D. Dry patches on the scalp: Dry patches can be a sign of conditions like seborrheic dermatitis or psoriasis, but they are not typically associated with pediculosis capitis.

A. Apex of the heart B. Brachial artery C. Carotid artery D. Radial artery

Correct Answer is B

Explanation

A. Apex of the heart: While the apex of the heart is a common site to listen to the heart sounds, it’s not typically used to measure the heart rate in infants.
B. Brachial artery: This is the correct answer. The brachial artery, located on the inside of the upper arm, is commonly used to assess the heart rate in infants.
C. Carotid artery: The carotid artery, located on the neck, is commonly used to assess the heart rate in adults, but it’s not typically used in infants.
D. Radial artery: The radial artery, located on the wrist, is also commonly used to assess the heart rate in adults, but it’s not typically used in infants.

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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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