A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Administer a saline enema for constipation.

Initiate contact precautions.

Encourage independence in the completion of ADLs.

Monitor oral mucosa daily.

Answer and Explanation

The Correct Answer is D

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

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Correct Answer is A

Explanation

A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.

B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.

C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.

D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.

A. Diarrhea B. Pinpoint-sized pupils C. Weight gain D. Bulimia

Correct Answer is B

Explanation

A. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.

B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.

C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.

D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.

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A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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Explanation

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