Nokea
A nurse in a health care facility is caring for a client who is receiving an antiemetic to control vomiting related to chemotherapy. Which of the following nursing diagnoses should the care plan for this client include?
- A. Risk for Imbalanced Fluid Volume
- B. Disturbed Sensory Perception
- C. Impaired Physical Mobility
- D. Ineffective Tissue Perfusion
Correct Answer: A
Rationale: The care plan should include Risk for Imbalanced Fluid Volume for the client receiving an antiemetic due to the possible fluid losses associated with vomiting as well as the possible decrease in fluid intake. Disturbed sensory perception, impaired physical mobility, and ineffective tissue perfusion are not applicable.
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A client is administered trimethobenzamide hydrochloride (Tigan) to control nausea and vomiting. The nurse would assess the client for which of the following?
- A. Acid rebound
- B. Neurotoxicity
- C. Blurred vision
- D. Bone softening
Correct Answer: C
Rationale: The nurse should monitor the client for blurred vision as an adverse reaction to the trimethobenzamide hydrochloride (Tigan). The nurse need not monitor the client for acid rebound, neurotoxicity, and bone softening as they are not adverse reactions to trimethobenzamide hydrochloride (Tigan). Acid rebound is an adverse reaction to calcium carbonate. Neurotoxicity and bone softening are adverse reactions to aluminum carbonate gel.
Which of the following antacids may produce constipation and should be used cautiously in clients who have chronic constipation?
- A. Calcium carbonate (Mylanta)
- B. Magnesium hydroxide (Milk of Magnesia)
- C. Magnesium oxide (Mag-Ox)
- D. Aluminum hydroxide (ALternaGEL)
- E. Sodium bicarbonate (Bell/ans)
Correct Answer: A,D
Rationale: The aluminum- and calcium-containing antacids may produce constipation. Magnesium- and sodium-containing antacids tend to have a laxative effect.
A client is receiving an antiemetic. The nurse identifies a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements? Which of the following would the nurse include in the client's plan of care?
- A. Remove items with strong smells and odors.
- B. Use mouthwash or frequent oral rinses.
- C. Make the environment as pleasant as possible.
- D. Explain that the drug may change the color of the stool.
- E. Follow the medication with a small amount of water.
Correct Answer: A,B,C
Rationale: When caring for a client receiving an antiemetic with a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements, the nurse makes the environment as pleasant as possible to enhance the client's appetite and removes items with strong smells and odors. The nurse gives the client mouthwash or frequent oral rinses to remove the disagreeable taste that accompanies vomiting. Stool color is unaffected. Liquid antacids could be followed with a small amount of water.
A client is taking ginger medicinally for motion sickness. The nurse would urge the client to use caution if the client has which medical condition?
- A. Gallstones
- B. Blood dyscrasia
- C. Parkinson's disease
- D. Severe liver disease
Correct Answer: A
Rationale: Ginger should be used with caution in clients with hypertension or gallstones and during pregnancy or lactation. Antiemetic prochlorperazine is contraindicated in clients with blood dyscrasia, Parkinson's disease, and severe liver disease.
Before administering a prescribed emetic, which of the following would the nurse need to assess?
- A. What chemicals or substances were ingested?
- B. What are the client's current medications?
- C. What time was the substance ingested?
- D. What is the client's blood pressure?
- E. What symptoms were noted before seeking treatment?
Correct Answer: A,C,E
Rationale: Before an emetic is given, it is extremely important to know the chemicals or substances that have been ingested, the time they were ingested, and what symptoms were noted before seeking medical treatment.