While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should:
1. Immediately stop the infusion
2. Lower the height of the enema container
3. Advance the enema tubing 2 to 3 inches
4. Clamp the tubing
ANS: 2
The nurse should lower the container if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effectiveness of the enema. If the nurse stops the infusion, the client will not receive all of the fluid, and the enema will be less effective. The nurse may slow the infusion until the abdominal cramping passes. The enema tubing should not be advanced further. The tubing may be clamped temporarily if fluid escapes around the rectal tube. The instillation should be slowed in the instance of abdominal cramping.
You might also like to view...
A client is receiving treatment with adrenocorticotropic hormone. The nurse would instruct the client to avoid receiving which vaccine? Select all that apply
A) Zostavax (shingles) B) Meruvax (rubella) C) Td (tetanus and diphtheria) D) Fluzone (influenza) E) Attenuvax (measles)
How does the nurse help the patient and family gain control of their lives?
A) By providing educational resources in the community B) By offering referrals to community social clubs C) By introducing the patient to other neurologically impaired people in the community D) By collaborating with other members of the health care team
The nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include?
a. "Apply antiembolism stockings before getting out of bed in the morning." b. "Clean venous ulcers with Betadine before applying a dressing." c. "Take 1 low-dose aspirin (81 mg) daily to prevent inflammation." d. "Remove and reapply a new DuoDerm dressing to your ulcers each day."
A nurse is teaching a class about the role of acute care in the nursing process. A student asks what type of prevention, if any, acute care mainly provides. The nurse replies
A. Primary B. Secondary C. Tertiary D. Quaternary