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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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A client with diabetes mellitus is scheduled for surgery. What is the most important preoperative instruction the nurse should provide?
- A. Take your insulin as usual
- B. Do not eat or drink after midnight
- C. Monitor your blood glucose closely
- D. Bring your glucose meter to the hospital
Correct Answer: B
Rationale: The most important preoperative instruction for a client with diabetes mellitus scheduled for surgery is to instruct them not to eat or drink after midnight. This instruction is crucial to maintain NPO (nothing by mouth) status before surgery, reducing the risk of aspiration during anesthesia. While taking insulin as usual (Choice A) is important, doses can be adjusted by the healthcare team. Monitoring blood glucose closely (Choice C) is essential but not as critical preoperatively. Bringing a glucose meter to the hospital (Choice D) can be helpful but is not as vital as maintaining NPO status.
A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?
- A. Moon face, slow wound healing, muscle wasting, sodium and water retention
- B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
- C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
- D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
Correct Answer: A
Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.
A client with a diagnosis of bipolar disorder is prescribed lithium. Which electrolyte imbalance should the nurse monitor for?
- A. Hyponatremia
- B. Hypokalemia
- C. Hypercalcemia
- D. Hypernatremia
Correct Answer: A
Rationale: The correct answer is A: Hyponatremia. Lithium can affect sodium levels in the body, potentially leading to hyponatremia, which is a condition characterized by low sodium levels. This imbalance requires close monitoring as it can lead to symptoms such as confusion, weakness, and even seizures. Choices B, C, and D are incorrect because lithium is not primarily associated with causing hypokalemia, hypercalcemia, or hypernatremia. While these imbalances can occur in certain conditions or with other medications, the main electrolyte imbalance to monitor when a client is prescribed lithium is hyponatremia.
A client undergoing chemotherapy reports a sudden onset of severe back pain. What should the nurse do first?
- A. Administer pain medication as prescribed
- B. Assess the pain's nature and intensity
- C. Encourage the client to rest and apply a hot pack
- D. Notify the physician immediately
Correct Answer: B
Rationale: The correct first action for the nurse is to assess the nature and intensity of the pain. This initial assessment is crucial in determining the underlying cause of the pain, whether it is related to the chemotherapy or another issue. Understanding the pain's characteristics will guide the nurse in implementing appropriate interventions and seeking timely medical assistance if needed. Administering pain medication without a thorough assessment may mask important symptoms and delay necessary treatment. Encouraging rest and hot pack application may be appropriate interventions but should come after assessing the pain. Notifying the physician immediately can be important but should follow the initial assessment to provide comprehensive information to the healthcare provider.
The nurse is caring for a client who is NPO (nothing by mouth) due to a small bowel obstruction. Which nursing intervention is most important?
- A. Monitor bowel sounds
- B. Provide frequent oral care
- C. Encourage ambulation
- D. Measure abdominal girth
Correct Answer: B
Rationale: Providing frequent oral care is crucial when a client is NPO to ensure comfort and prevent drying of the oral mucosa. In this situation, the priority is maintaining oral hygiene to prevent complications such as oral mucosa breakdown. Monitoring bowel sounds may be important in assessing bowel activity, but it is not the priority when the client is NPO due to a small bowel obstruction. Encouraging ambulation can be beneficial for other conditions, but in this case, oral care takes precedence. Measuring abdominal girth is more relevant for assessing abdominal distention, which is not the priority when the client is NPO. Therefore, the most important nursing intervention is to provide frequent oral care.