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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Performing neurovascular checks of the extremities is critical to detect signs of complications such as impaired circulation or nerve damage, which can occur after orthopedic surgery. This assessment is essential for early identification of potential issues.
B. While performing exercises of the ankle and toes is important for preventing complications like deep vein thrombosis, it is secondary to ensuring neurovascular integrity.
C. Instructing the client on the use of crutches is necessary for mobility and safety, but it follows the priority of monitoring for neurovascular complications.
D. Medicating the client for pain is important for comfort, but addressing potential neurovascular issues is a higher priority in the immediate postoperative period to prevent serious complications.
Correct Answer is C
Explanation
A. A platelet count of 150,000/mm³ is within the lower end of the normal range and might be monitored but is not the highest priority for intervention in the context of HIV.
B. A positive Western blot test confirms HIV infection but does not provide information on the current immune status or disease progression.
C. A CD4-T-cell count of 180 cells/mm³ indicates significant immunosuppression and is critical as it reflects the progression of HIV and the risk of opportunistic infections. This value is a priority because it directly affects the client’s immune status and potential treatment strategies.
D. A WBC count of 5,000/mm³ is within the normal range and is less critical compared to the CD4-T-cell count, which provides more specific information regarding the client’s HIV status and risk for opportunistic infections.
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