what is the priority intervention when a patient experiences abdominal cramping during enema administration
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What is the priority intervention when a patient experiences abdominal cramping during enema administration?

Correct answer: A

Rationale: The correct answer is to lower the height of the enema solution container. This action can help relieve abdominal cramping by slowing the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is not the priority as adjusting the height of the container can often resolve the issue without needing to stop the procedure completely. Choice C, continuing the enema at a slower rate, may not address the immediate discomfort experienced by the patient. Choice D, increasing the flow of the enema solution, can exacerbate the cramping and should be avoided.

2. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

Correct answer: B

Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.

3. When providing discharge teaching to a patient who underwent cataract surgery, what should the patient avoid?

Correct answer: A

Rationale: The correct answer is to avoid NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding after cataract surgery due to their anticoagulant properties. Bright lights (choice B) are not contraindicated post-cataract surgery unless the patient experiences discomfort or sensitivity. Alcohol consumption (choice C) is generally not restricted after cataract surgery, but moderation is recommended. Phosphorus-rich foods (choice D) are not directly related to cataract surgery postoperative care.

4. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease are at risk of wandering and becoming lost. Providing supervision helps prevent them from getting injured or lost. Choice A is incorrect because extensive details may overwhelm clients with Alzheimer's. Choice B is incorrect because limiting activities can lead to boredom and behavioral issues. Choice C is incorrect because speaking calmly and at a moderate volume helps to reduce agitation and confusion in clients with Alzheimer's.

5. What ECG changes are associated with hyperkalemia?

Correct answer: B

Rationale: Hyperkalemia is known to cause ST depression on an ECG. Flattened T waves are more commonly seen in hypokalemia. Prominent U waves are associated with hypokalemia rather than hyperkalemia. Elevated ST segments are not typical findings in hyperkalemia.

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