While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Appeared in: PGIMER Sangrur NO - 2023

Explanation

Abdominal cramping during an enema typically indicates the solution is flowing too quickly, causing rapid bowel distention and spasms.
Clamping the tubing immediately stops the flow of fluid, giving the intestinal muscles time to relax and the cramping to subside.
After the cramping resolves, the nurse can unclamp the tubing and resume the enema at a slower rate, often by lowering the height of the enema bag.

Option A: This action, known as the Valsalva maneuver, increases intra-abdominal pressure and can worsen cramping or cause premature expulsion of the enema solution.
Option C: While some mild cramping can be expected, this response dismisses the client's discomfort and is not a therapeutic nursing intervention. The nurse must act to relieve the pain.
Option D: Raising the container increases the height of the fluid column, which speeds up the flow rate due to gravity. This will worsen the bowel distention and cramping.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of complications during enema administration to guide bedside assessment, documentation, and the next nursing action.
Patient safety during enema administration requires the nurse to respond immediately to signs of distress like cramping. Stopping the flow is a critical first step to prevent severe discomfort or injury.
This scenario highlights the importance of therapeutic nursing actions. Instead of just stating a fact (cramping is common), the nurse must perform an action to alleviate the symptom.
What if? If the client reported feeling dizzy and faint in addition to cramping, the nurse should immediately stop the enema and assess vital signs, as this could indicate a vagal response, which is a more serious complication requiring immediate intervention and notification of the provider.

How to Approach the Question

First, identify the core problem: the client is experiencing abdominal cramping during an enema.
Recall the physiology of an enema. The fluid instillation stretches the bowel wall. Cramping indicates the stretching is happening too quickly or is too intense.
Analyze each option based on its effect on fluid flow and abdominal pressure.
Option A (bearing down) increases pressure, which would worsen the problem.
Option B (clamping) stops the fluid flow, which would relieve the stretching. This is a logical intervention.
Option C (reminding) is a passive response and does not solve the physical problem.

Concept Tested & Keywords

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E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 51-53

E6 Nursing Fundamentals Taylor p. 664-666

Practise the full PGIMER Sangrur NO - 2023

Attempt every question from this paper in a timed mock, then review the full solution for each one.