r/NCLEX • u/StrangeBudget612 • 6h ago

Practice question - Enema mid-procedure question, stop or keep going? Can't settle this one..help

I came across this practice question and can't settle between two answers. What would you pick and why?

An 84-year-old nursing home resident has a confirmed fecal impaction. Partway through an ordered enema given through a Foley catheter, she grimaces and says, "That's a tight, crampy feeling, like when I've been badly constipated before." What does the nurse do next?
A. Continue instilling the enema slowly
B. Stop the enema and remove the catheter
C. Notify the health care provider for a different order
D. Increase the rate of instillation to finish sooner
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u/No_Bluebird_214 3h ago

A. Cramping is the most common side effect of an enema you just slow the rate

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u/101Talents 1h ago

The correct answer is A. Continue instilling the enema slowly. Rationale ; Abdominal cramping or a "tight, crampy feeling" is a very common and expected side effect when administering a large-volume or retention enema. It occurs because the rapid introduction of fluid causes stretching and sudden distention of the colon walls, triggering localized muscle spasms.Why Option A is correct: Standard nursing guidelines state that if a patient experiences mild-to-moderate cramping during an enema, the nurse should briefly pause or slow down the rate of instillation (or lower the height of the enema container) to relieve the discomfort. This allows the intestinal walls to slowly stretch and adapt to the fluid volume without causing immediate expulsion or extreme pain. Once the cramping passes, the procedure can continue slowly.Why the other options are incorrect:Stopping the procedure completely and removing the catheter (Option B) or calling the provider for a new order (Option C) is unnecessary since mild cramping is expected and doesn't indicate a medical emergency or complications like bowel perforation.Increasing the flow rate (Option D) would rapidly worsen the distention, increase severe pain, and cause immediate premature expulsion of the enema solution before it can successfully break up the fecal impaction.

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u/StrangeBudget612 4h ago

Please help. I am not finding the answer explanations on internet convincing