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 A

Explanation

A. Placing the client on their left side in Trendelenburg position (head down, feet up) helps trap any air in the right atrium and prevents it from entering the pulmonary circulation, reducing the risk of an air embolism affecting the lungs.

B. Replacing the infusion system does not address the immediate need to manage an air embolism. The primary intervention is positioning and monitoring.

C. Removing the catheter is not the initial priority. The focus should be on managing the air embolism and ensuring the client is in the correct position.

D. Preparing for chest tube insertion is not appropriate unless there is evidence of a pneumothorax or hemothorax. The immediate concern is managing the air embolism.

A. An urge to void despite having an indwelling urinary catheter B. Output of burgundy colored urine C. Pulse rate of 88/min D. Oral temperature of 38.2° C (100.76° F)

Correct Answer is B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

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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

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