what should the nurse do when a patient experiences abdominal cramping during enema administration

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What should the nurse do when a patient experiences abdominal cramping during enema administration?

A. Lower the height of the enema solution container
B. Stop the procedure and remove the tubing
C. Continue the enema at a slower rate
D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

2. What are the expected signs in a patient with compartment syndrome?

A. Unrelieved pain, pallor, and pulselessness
B. Fever and infection
C. Localized redness and swelling
D. Loss of sensation in the affected area

Correct answer: A

Rationale: In a patient with compartment syndrome, the classic signs include unrelieved pain, pallor, and pulselessness. These signs indicate compromised circulation and neurovascular function in the affected compartment. Fever and infection (Choice B) are not typical signs of compartment syndrome. Localized redness and swelling (Choice C) can be seen in other conditions like cellulitis but are not specific to compartment syndrome. Loss of sensation in the affected area (Choice D) may occur in some cases but is not as specific or consistent as unrelieved pain, pallor, and pulselessness in diagnosing compartment syndrome.

3. What lab value should be monitored in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. Serum albumin levels
C. Hemoglobin levels
D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 T-cell count below 180 cells/mm3 signifies severe immunosuppression and an increased risk of opportunistic infections. Serum albumin levels (choice B) are important for nutritional status assessment but not specific to HIV monitoring. Hemoglobin levels (choice C) are important for assessing anemia but do not directly reflect HIV disease progression. White blood cell count (choice D) is a general marker of inflammation and infection, but monitoring CD4 T-cell count is more specific and crucial in managing HIV.

4. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?

A. Decreased deep tendon reflexes
B. Positive Chvostek's sign
C. Hyperactive bowel sounds
D. Dry mucous membranes

Correct answer: A

Rationale: Corrected deep tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness. Positive Chvostek's sign is associated with hypocalcemia, hyperactive bowel sounds are not typically related to hyponatremia, and dry mucous membranes are more commonly seen with dehydration.

5. What is the first medication to give to a patient with an allergic reaction causing wheezing?

A. Albuterol 3 ml via nebulizer
B. Methylprednisolone 100 mg IV
C. Cromolyn 20 mg via nebulizer
D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A, Albuterol 3 ml via nebulizer. Albuterol is a fast-acting bronchodilator that helps relieve wheezing by relaxing the muscles in the airways, making it the first-line treatment for wheezing caused by bronchospasms in allergic reactions. Methylprednisolone (Choice B) is a corticosteroid used for its anti-inflammatory properties and is typically given after bronchodilators. Cromolyn (Choice C) is a mast cell stabilizer that is used for the prevention of asthma symptoms, not for immediate relief. Aminophylline (Choice D) is a bronchodilator that is less commonly used nowadays due to its narrow therapeutic window and potential for toxicity.