Answer to Question 1
B
The nurse should slow the rate of infusion if the client complains of abdominal cramping. Cramping may prevent the client from retaining all of the fluid, which would alter the effective-ness 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. However, in the instance of abdominal cramping, the nurse's first action should be to slow the rate of infusion.
Answer to Question 2
D
The collective body of knowledge is called the metaparadigm concept, and includes the concepts of person, environment, health, and nursing.
Family is not part of the metaparadigm.
Health is the goal of nursing care.
Nursing care refers to both the individual and society and to all clients, sick or well.
Client on IV patient-controlled analgesia (PCA).
Abdominal contours.
Administering a Disposable Enema
Apply the substance to the client’s upper chest.
Testing the Achilles tendon reflex with client in a sitting position