Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Lower the height of the solution container.
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. Encourage the client to bear down.
Encouraging the client to bear down may increase discomfort and is not recommended during the administration of an enema.
C. Allow the client to expel some fluid before continuing.
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. Stop the enema and document that the client did not tolerate the procedure.
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.
This question is an excerpt from Nurse Dive's nursing test bank - Ati critical care midterm proctored exam. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
A. Include foods high in fiber.
While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoid foods high in fat.
Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. Avoid foods high in sodium.
High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Include foods high in starch and proteins.
Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.
Full Explanation
A. While high-fiber foods are generally healthy, they are not specifically targeted to prevent biliary colic. The primary dietary focus should be on fat intake.
B. Avoiding foods high in fat is crucial for clients with chronic cholecystitis, as fatty foods can trigger biliary colic by stimulating the gallbladder to contract.
C. High sodium intake is more related to cardiovascular and kidney health and is not specifically implicated in biliary colic.
D. Including foods high in starch and proteins is not as critical as avoiding fatty foods to prevent episodes of biliary colic.
A nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching?
A. You may donate blood 6 months after completing the medication regimen.
Clients with hepatitis B should never donate blood, even after completing treatment, as they can remain carriers of the virus.
B. Rest frequently throughout the day.
Resting frequently is essential for clients with hepatitis B as it helps the body recover and conserve energy during the healing process.
C. Consume a high-protein diet.
A high-protein diet is not recommended for hepatitis B patients; a balanced diet with adequate calories and nutrients is more appropriate to support liver health.
D. Take acetaminophen every 4 hr, as needed, for discomfort.
Acetaminophen is metabolized by the liver and should be used cautiously or avoided in clients with hepatitis B to prevent further liver damage.
Full Explanation
A. Clients with hepatitis B should never donate blood, even after completing treatment, as they can remain carriers of the virus.
B. Resting frequently is essential for clients with hepatitis B as it helps the body recover and conserve energy during the healing process.
C. A high-protein diet is not recommended for hepatitis B patients; a balanced diet with adequate calories and nutrients is more appropriate to support liver health.
D. Acetaminophen is metabolized by the liver and should be used cautiously or avoided in clients with hepatitis B to prevent further liver damage.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
A. Relieve the client's pain.
Pain relief is important, but the immediate priority post-surgery is to ensure the client’s airway is not compromised.
B. Promote oral hygiene.
Promoting oral hygiene is necessary to prevent infection, but it is not the immediate priority.
C. Prevent aspiration.
Preventing aspiration is the priority because the client’s jaw is wired shut, increasing the risk of aspiration which can lead to serious respiratory complications.
D. Ensure adequate nutrition.
Ensuring adequate nutrition is important for recovery, but it comes after ensuring the client’s airway and breathing are safe and stable.
Full Explanation
A. Pain relief is important, but the immediate priority post-surgery is to ensure the client’s airway is not compromised.
B. Promoting oral hygiene is necessary to prevent infection, but it is not the immediate priority.
C. Preventing aspiration is the priority because the client’s jaw is wired shut, increasing the risk of aspiration which can lead to serious respiratory complications.
D. Ensuring adequate nutrition is important for recovery, but it comes after ensuring the client’s airway and breathing are safe and stable.