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

Lower the height of the solution container.

Encourage the client to bear down.

Allow the client to expel some fluid before continuing.

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

Answer and Explanation

The Correct Answer is A

A. Lowering the height of the solution container will slow the rate of instillation, reducing the intensity of the cramps and allowing the client to tolerate the enema better.
B. Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allowing the client to expel some fluid before continuing might provide temporary relief but does not address the rate of fluid instillation, which is the primary cause of cramping.
D. Stopping the enema and documenting the intolerance is not the first step; adjusting the rate of administration should be tried first to help the client tolerate the procedure.

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Correct Answer is C

Explanation

A. The Mantoux test (TB skin test) is used for screening and indicates exposure to TB but cannot confirm active disease.
B. A chest x-ray can show signs suggestive of TB, such as lung lesions, but it does not confirm the presence of the bacteria.
C. A sputum culture for acid-fast bacillus is the most reliable test for confirming active pulmonary TB as it identifies the presence of Mycobacterium tuberculosis in the sputum.
D. A sputum smear can detect acid-fast bacilli but is less definitive than a culture, which confirms the diagnosis.

A. Urinary output B. Arterial blood gases C. Chest tube drainage D. Pain level

Correct Answer is C

Explanation

A. Urinary output is important but secondary to respiratory concerns in this postoperative context.
B. Arterial blood gases provide valuable information but are less immediate compared to issues directly affecting lung function.
C. Chest tube drainage is critical to monitor for complications such as pneumothorax or hemothorax, which are significant concerns post-thoracotomy and lobectomy.
D. Pain level is important for patient comfort but does not have the immediate impact on recovery compared to chest tube drainage.

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nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having 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 nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Correct Answer is C

Explanation

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

Correct Answer is C

Explanation

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