Difficulty: Medium
Average Score: 62%
Simulated
A client receiving a cleansing enema reports mild cramping. After a few minutes, he asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
Correct answer
D
Rationale
The correct answer is D: Lower the height of the solution bag. Lowering the height of the solution bag will decrease the rate at which the enema solution is flowing, which can help alleviate the cramping the client is experiencing. By slowing down the flow, the client may be able to tolerate the procedure better and complete the enema successfully.
A: Pausing the enema and giving pain medication does not address the underlying issue of the flow rate causing cramping.
B: Discontinuing the enema may not be necessary if adjusting the flow rate can alleviate the cramping.
C: Continuing the enema without addressing the client's discomfort is not appropriate and may lead to increased distress.
A: Pausing the enema and giving pain medication does not address the underlying issue of the flow rate causing cramping.
B: Discontinuing the enema may not be necessary if adjusting the flow rate can alleviate the cramping.
C: Continuing the enema without addressing the client's discomfort is not appropriate and may lead to increased distress.