Nokea
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?
- A. Use sunblock or protective clothing when outdoors.
- B. Include the child in regular outings with the family.
- C. Obtain any childhood vaccinations that are not up-to-date.
- D. Use diluted commercial mouthwash for mouth care.
Correct Answer: A
Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.
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What is the most important action to prevent complications while caring for a client receiving enteral nutrition via a nasogastric tube?
- A. Check tube placement before each feeding
- B. Flush the tube with water before and after each feeding
- C. Elevate the head of the bed to 30 degrees
- D. Administer the feeding at room temperature
Correct Answer: A
Rationale: Checking tube placement before each feeding is crucial to prevent aspiration, a serious complication of enteral nutrition. Ensuring the tube is correctly positioned in the stomach helps avoid the risk of the feeding going into the lungs, which can lead to aspiration pneumonia. Flushing the tube with water (Choice B) is important for maintaining tube patency but is not the most critical action to prevent complications. Elevating the head of the bed (Choice C) helps reduce the risk of aspiration but is not as crucial as verifying tube placement. Administering the feeding at room temperature (Choice D) is more related to patient comfort and does not directly address the prevention of complications associated with enteral nutrition via a nasogastric tube.
The client is 4 hours post-operative from a cesarean section and complains of gas pain and bloating. What non-pharmacological intervention can the nurse provide?
- A. Encourage the client to ambulate
- B. Apply a heating pad
- C. Provide a carbonated beverage
- D. Teach relaxation techniques
Correct Answer: A
Rationale: The correct answer is to encourage the client to ambulate. Early ambulation helps alleviate gas pain and bloating by promoting gastrointestinal motility and reducing the accumulation of gas in the abdomen. Applying a heating pad may provide comfort for some types of pain but is not specifically effective for gas pain. Providing a carbonated beverage can actually worsen gas pain due to the introduction of more gas into the digestive system. Teaching relaxation techniques may be beneficial for overall comfort but may not directly address the gas pain and bloating experienced post-cesarean section.
A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?
- A. Administer a bronchodilator as prescribed
- B. Encourage the client to drink fluids
- C. Place the client in an upright position
- D. Assess the client's peak flow rate
Correct Answer: A
Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.
Which membrane lines the abdominal cavity?
- A. Perineum
- B. Pericardium
- C. Pleura
- D. Peritoneum
Correct Answer: D
Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.
The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?
- A. Take the medication with or without food.
- B. Report any increase in suicidal thoughts.
- C. Avoid foods high in tyramine.
- D. Expect improvement within 24 hours.
Correct Answer: B
Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.