Nokea
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
- A. Have the client hold his breath briefly
- B. Discontinue the fluid instillation
- C. Remind the client that cramping is common at this time
- D. Lower the enema fluid container
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
You may also like to solve these questions
A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all.
- A. 905
- B. 825
- C. 1,000
- D. 840
- E. 935
Correct Answer: A,D
Rationale: The correct answers are A and D. Medications can generally be administered within 30 minutes before or after the scheduled time. A (905) and D (840) fall within this window for a 0900 scheduled administration. B (825) is too early, C (1,000) is too late, and E (935) is also too late. It's important to administer medications close to the scheduled time to maintain therapeutic levels in the body.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
- A. The physical therapist didn't ambulate the client today
- B. The skin barrier's seal stays on in bed but loosens when the client stands.
- C. The client seemed to welcome having a 'day off' from physical therapy
- D. The wound care nurse will see the client later today
- E. The client ate all the food on her lunch tray
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D. Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage. Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing. Choice D is essential to include as it informs about the upcoming visit from the wound care nurse. Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk medication for the control of seizures. Which of the following statements by the nurse is appropriate?
- A. This medication is prescribed if necessary but is known to cause adverse effects to the fetus.
- B. This medication has evidence indicating that it is safe to take during pregnancy and will not harm the fetus.
- C. This medication cannot be taken during pregnancy because the risk outweighs the potential benefits.
- D. This medication hasn't been studied in pregnant women but is believed to be safe for the fetus.
Correct Answer: A
Rationale: The correct answer is A. Category D medications have shown evidence of risk to the fetus in human studies but potential benefits may outweigh risks in certain situations. The nurse should inform the client about the risks and benefits of continuing the medication while trying to conceive. Choice B is incorrect because Category D medications are not considered safe during pregnancy. Choice C is incorrect as it is not entirely true that the risk always outweighs the benefits. Choice D is incorrect because assuming safety without evidence is risky. The nurse should provide accurate information to guide the client's decision-making.
A nurse is preparing to administer methylprednisolone acetate (Depo-Medrol) 10 mg by IV bolus. The amount available is 40 mg/mL. How many mL should the nurse administer?
Correct Answer: 0.3
Rationale: Correct Answer: 0.3 mL
Rationale:
1. Calculate the total dose needed: 10 mg.
2. Determine the concentration: 40 mg/mL.
3. Use the formula: dose needed / concentration available = volume to administer.
4. Plug in the values: 10 mg / 40 mg/mL = 0.25 mL.
5. Round up to the nearest practical dose increment: 0.3 mL.
Summary:
Choice A (0.5 mL): Incorrect, as it does not accurately calculate the volume needed.
Choices B-G: Irrelevant, as they do not follow the correct calculation method.