Fundamentals of Nursing Q 560
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
A. Have a client hold his breath briefly.
B. Discontinue the fluid installation.
C. Remind the client that cramping is common at this time.
D. Lower the enema fluid container.
Correct Answer: D. Lower the enema fluid container.
To relieve the client’s discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container. An enema may be helpful when there is a problem forming or passing stool. The colon, also called the large intestine or large bowel, is a long, hollow organ in the abdomen. It plays an important role in digestion by removing water from digested material and forming feces (stool). In some circumstances, due to diet, medical condition, or medication, among other possible causes, the bowel may form stool that is hard to pass easily resulting in constipation.
Option A: Taking slow, deep breaths is more therapeutic for easing discomfort than holding the breath. A cleansing enema can also lower the amount of bacteria in the colon and reduce the risk of infection for certain surgeries.
Option B: The nurse should stop the installation if the client’s abdomen becomes rigid and distended or if the nurse notes bleeding from the rectum. An enema should not be painful when administered properly. The client may feel fullness, mild pressure, or brief, minimal cramping during the procedure. The client may also feel like he needs to have a bowel movement.
Option C: This intervention is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it. The client may take a few long, deep breaths to help himself relax. If he has pain or discomfort while self-inserting an enema, stop and contact the doctor.