ATI RN
ATI Fundamentals Exam East Wick College Questions
Extract:
Question 1 of 5
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
Correct Answer: D
Rationale: The correct answer is D: Lower the height of the solution container. Lowering the height of the solution container will decrease the force of the fluid entering the client's rectum, which can help alleviate the cramping sensation. By reducing the pressure, the client may experience less discomfort during the enema administration.
Choice A (Allow the client to expel some fluid before continuing) is incorrect because expelling fluid may not necessarily reduce the cramping, as the main issue is the pressure of the solution entering the rectum.
Choice B (Encourage the client to bear down) is incorrect as bearing down may increase the discomfort by increasing abdominal pressure.
Choice C (Stop the enema and document that the client did not tolerate the procedure) is premature and does not address the issue at hand.
In summary, lowering the height of the solution container is the most appropriate action to relieve the client's discomfort during the tap-water enema administration.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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