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 B

Explanation

A. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.

B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.

C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.

D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.

A. Decreased specific gravity B. Increased pulmonary artery wedge pressure (PAWP) C. Decreased brain natriuretic peptide (BNP) D. Elevated central venous pressure (CVP) and jugular vein distention

Correct Answer is D

Explanation

A. Decreased specific gravity is not typical of right-sided heart failure. Increased specific gravity is often associated with fluid retention.
B. PAWP is more relevant for left-sided heart failure; right-sided heart failure would typically not show an increase in PAWP.
C. BNP levels usually increase in heart failure, including right-sided heart failure, not decrease.
D. Elevated CVP and jugular vein distention are classic signs of right-sided heart failure due to increased venous pressure and fluid overload.

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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 in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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