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. Monitoring cardiac rhythm is not specifically necessary for ethambutol therapy.
B. Urine output is not a primary concern related to ethambutol use.
C. Visual acuity should be monitored because ethambutol can cause optic neuritis, which may lead to vision changes and requires regular assessment.
D. Skin color is not a specific concern with ethambutol therapy; monitoring for visual changes is more pertinent.

A. "I need to drink 8 cups of liquid each day." B. "I will need to wipe my perineal area from back to front after urination." C. "I will need to empty my bladder regularly and completely." D. "I will need to drink apple cider vinegar each day."

Correct Answer is B

Explanation

A. Drinking 8 cups of liquid daily is a correct measure to help flush out bacteria and prevent UTIs.
B. Wiping from back to front can increase the risk of transferring bacteria from the rectal area to the urethra; the correct practice is to wipe from front to back.
C. Regular and complete bladder emptying helps reduce the risk of bacterial growth in the urinary tract.
D. Drinking apple cider vinegar is not a standard recommendation for preventing UTIs; more evidence-based practices should be emphasized.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

Correct Answer is C

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A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

Correct Answer is B

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