The student nurse is administering a large-volume enema to a client. The client complains of abdominal cramping. What should the student nurse do first?
A) Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate.
B) Stop the administration of the enema and notify the physician.
C) Stop the adminstration of the enema momentarily.
D) Increase the flow of the enema until all of the solution has been administered.
Ans: C
Feedback:
If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.
You might also like to view...
The nurse expects an adult with normal kidney function to void a minimum of ____ mL of urine in 4 hours
ANS:
A patient was recently exposed to infectious microorganisms and many T lymphocytes are now differentiating into killer T cells. This process characterizes what stage of the immune response?
A) Effector B) Proliferation C) Response D) Recognition
Which of the following would describe nursing practice without theory?
A) Rote performance of task B) Informed clinical paths based on evidence C) Updated and current assessment techniques D) Cultural considerations in patient care
Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. These modes are "cultural care preservation or maintenance," "cultural care accommodation," and "cultural care repatterning
" When assessing patients during the admission process, the nurse utilizes a. These action modes in a distinct order. b. These action modes individually, one at a time. c. Only one action mode per patient. d. All these action modes simultaneously.