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A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
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The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?
- A. To stabilize fluid and electrolyte balance.
- B. To minimize oxygen consumption.
- C. To increase client and family comfort.
- D. To prevent infection.
Correct Answer: B
Rationale: A dimly lit environment and limited visitors reduce stimulation, minimizing oxygen consumption in a client with gastric bleeding, who may be hypoxic due to anemia. Comfort is secondary, and these measures do not directly stabilize fluids or prevent infection.
A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment?
- A. Vitamin K.
- B. Dextrose 50%.
- C. Activated charcoal powder.
- D. Sodium thiosulfate.
Correct Answer: C
Rationale: Activated charcoal is used to adsorb aspirin in the stomach, reducing absorption in an overdose. Vitamin K is for anticoagulant reversal, dextrose for hypoglycemia, and sodium thiosulfate for cyanide poisoning.
The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.
The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply.
- A. Presbyopia
- B. Tinnitus
- C. Vertigo
- D. Dyskinesia
- E. Hearing loss
Correct Answer: B,C,E
Rationale: Meniere's disease is characterized by tinnitus (ringing in the ears), vertigo (spinning sensation), and hearing loss due to inner ear dysfunction. Presbyopia (age-related vision loss) and dyskinesia (abnormal movements) are not associated with Meniere's disease.
A client post-lithotripsy asks about expected symptoms. The nurse should explain:
- A. Bruising at the site.
- B. Severe flank pain.
- C. Clear urine output.
- D. Fever above 102°F.
Correct Answer: A
Rationale: Bruising is common post-lithotripsy due to shock wave impact on tissues.