Ati Med-Surg Gastrointestinal Study Guide 2024 | Detailed Ans

ATI MED-SURG GASTROINTESTINAL STUDY GUIDE 2024 | DETAILED ANSWER KEY & COMPREHENSIVE REVIEW 1. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? A. Lower the height of the solution container. B. Encourage the client to bear down. C. Allow the client to expel some fluid before continuing. D. Stop the enema and document that the client did not tolerate the procedure. Correct Answer: A. Lower the height of the solution container. Rationale A: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed. Rationale B: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema. Rationale C: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema. Rationale D: Cramping