a patient who received an enema reports abdominal cramping what should the nurse do

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. A patient who received an enema reports abdominal cramping. What should the nurse do?

A. Increase the flow of the enema solution
B. Lower the height of the enema solution container
C. Remove the enema tubing
D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

2. What is the correct response when a patient receiving an enema reports abdominal cramping?

A. Lower the height of the enema container
B. Stop the enema procedure
C. Remove the enema tubing
D. Continue the enema at a slower rate

Correct answer: A

Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.

3. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

A. Teach the client to report findings of IV extravasation
B. Evaluate the patency of the IV
C. Consult with the pharmacist about the prescription
D. Verify the prescription with the provider

Correct answer: D

Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.

4. What symptoms are associated with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Loss of motor function with nausea
D. Severe headache and vomiting

Correct answer: A

Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.

5. What does continuous bubbling in the chest tube water seal chamber indicate?

A. An air leak
B. Normal chest tube function
C. A blocked chest tube
D. Continuous drainage from the chest tube

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.