Author Question: While administering an enema, the client complains of abdominal cramping. What should the nurse do? ... (Read 119 times)

BRWH · **on:** Jul 23, 2018

While administering an enema, the client complains of abdominal cramping. What should the nurse do?

1. Raise the height of the solution container.
2. Clamp the flow for 30 seconds, and restart at a slower rate.
3. Discontinue the enema infusion.
4. Assist the client to a supine position.

Question 2

The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care.

1. Clean and dry the peristomal skin and stoma.
2. Prepare and apply the skin barrier.
3. Empty the pouch and remove the ostomy barrier.
4. Assess the stoma and peristomal skin.
5. Apply the pouch.
6. Place a piece of tissue or gauze over the stoma and change it as needed.

14vl19 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: Raising the height of the enema solution container will cause the solution to infuse faster, leading to more abdominal cramping.
Rationale 2: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution.
Rationale 3: The enema should not be discontinued.
Rationale 4: The supine position will not reduce the client's abdominal cramping.

Answer to Question 2

Correct Answer: 3,1,4,6,2,5
Rationale: When caring for a client with an ostomy, the nurse should: 1) empty the pouch and remove the ostomy barrier; 2) clean and dry the peristomal skin and stoma; 3) assess the stoma and peristomal skin; 4) place a piece of tissue or gauze over the stoma and change it as needed; 5) prepare and apply the skin barrier; and 6) apply the pouch.