A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Assist the client to a left side-lying position with the right knee flexed.

Prepare the client for a chest x-ray.

Administer a cleansing enema.

Auscultate the client’s bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assisting the client to a left side-lying position with the right knee flexed is a common position for administering an enema. However, this action alone would not address the client’s immediate need for relief from constipation.

Choice B rationale

Preparing the client for a chest x-ray would not be the most appropriate action based on the client’s symptoms. The client is experiencing abdominal pain and constipation, which are not typically associated with conditions that would require a chest x-ray.

Choice C rationale

Administering a cleansing enema is the correct action. The client has not had a bowel movement for the past 7 days and reports abdominal pain. These symptoms, along with the findings from the abdominal x-ray, suggest that the client is experiencing constipation. A

cleansing enema can help to relieve constipation by stimulating bowel movements and removing impacted fecal matter.

Choice D rationale

Auscultating the client’s bowel sounds is an important part of assessing the client’s gastrointestinal status. However, given the client’s symptoms and the results of the abdominal x-ray, administering a cleansing enema would be the most appropriate action.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for Bleeding as evidenced by the Decrease in Platelet count from 350,000/mm² to 100,000/mm².

Rationale for Bleeding: Platelets are a crucial component of the blood that helps in clotting and preventing excessive bleeding. A decrease in platelet count from 350,000/mm² to 100,000/mm² is significant and puts the client at risk for bleeding. This is because when platelet levels fall below the normal range (150,000 to 400,000/mm²), the body’s ability to form clots and stop bleeding is compromised.

Rationale for Anemia: The client’s Hemoglobin level has decreased from 15 g/dL to 12 g/dL, which is at the lower end of the normal range (12 to 16 g/dL). However, it is still within the normal range, so the client is not currently at risk for anemia.

Rationale for Infections: The client’s White Blood Cell (WBC) count has decreased from 8,000/mm² to 6,000/mm², but it is still within the normal range (5,000 to 10,000/mm²). Therefore, the client is not currently at risk for infections.

Rationale for Cardiac arrhythmias: The client’s Potassium level has slightly decreased from 3.7 mEq/L to 3.6 mEq/L, but it is still within the normal range (3.5 to 5 mEq/L). Therefore, the client is not currently at risk for cardiac arrhythmias.

A. Insert the needle at a 15-degree angle. B. Aspirate for blood return before administration. C. Administer the medication into the abdomen. D. Massage the site after the injection.

Correct Answer is C

Explanation

Choice A rationale

Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.

Choice B rationale

Aspirating for blood return before administration is not necessary when administering heparin.

Choice C rationale

Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.

Choice D rationale

Massaging the site after the injection is not recommended as it can cause bruising.

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A client in the emergency department reports abdominal pain and has not had a bowel movement for the past 7 days. Based on the client’s clinical findings, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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Correct Answer is C

Explanation

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