Nokea
A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
- A. Administer I.V. dextrose 5% in 0.45% normal saline solution.
- B. Schedule client for a sigmoidoscopy in the morning.
- C. Give 1 unit fresh frozen plasma (FFP).
- D. Administer vitamin K (AquaMEPHYTON) 2.5 mg.
- E. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sigmoidoscopy.
- F. Administer Fleet enema.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
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The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)?
- A. Dizziness.
- B. Biliary colic.
- C. Bleeding.
- D. Urine retention.
Correct Answer: A
Rationale: Naloxone can cause dizziness due to rapid reversal of opioid effects, leading to autonomic changes. This is a common side effect to monitor in surgical clients.
A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
- A. Decreased mental status.
- B. Elevated blood pressure.
- C. Decreased urine output.
- D. Labored respirations.
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (A) due to ammonia buildup. Elevated blood pressure (B), decreased urine output (C), and labored respirations (D) are not primary indicators.
The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema:
- A. Can perforate an intestinal abscess.
- B. Would greatly increase the client's pain.
- C. Is of minimal diagnostic value in diverticulitis.
- D. Is too lengthy a procedure for the client to tolerate.
Correct Answer: A
Rationale: A barium enema is avoided in acute diverticulitis because it can perforate an intestinal abscess, worsening the condition. It may cause discomfort but is not primarily avoided for pain, diagnostic value, or procedure length. CN: Reduction of risk potential; CL: Apply
The most important long-term goal for a client with hypertension would be to:
- A. Learn how to avoid stress.
- B. Explore a job change or early retirement.
- C. Make a commitment to long-term therapy.
- D. Lose weight.
Correct Answer: C
Rationale: Committing to long-term therapy (e.g., medication, lifestyle changes) is critical for sustained blood pressure control and prevention of complications.