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A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
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The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation?
- A. Combination chemotherapy is used to interrupt cell growth cycle at different points.'
- B. Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.'
- C. Combination chemotherapy is used to decrease resistance.'
- D. Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent.'
Correct Answer: B
Rationale: Combination chemotherapy targets cancer cells at different cell cycle stages, reduces resistance, and minimizes toxicity by using lower doses of multiple drugs. It does not treat side effects; supportive care does. This statement indicates a need for further explanation.
Which assessment is most important for a client with a traumatic brain injury?
- A. Glasgow Coma Scale.
- B. Blood glucose levels.
- C. Electrolyte panel.
- D. Pain assessment.
Correct Answer: A
Rationale: The Glasgow Coma Scale is critical to assess neurological status and guide management in traumatic brain injury.
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which of the following about why dangerous abbreviations need to be eliminated? Select all that apply.
- A. To ensure efficient and accurate communication.
- B. To prevent medication errors.
- C. To ensure client safety.
- D. To make it easier for clients to understand the medication orders.
- E. To make data entry into a computerized health record easier.
Correct Answer: A,B,C
Rationale: Eliminating dangerous abbreviations ensures clear communication, prevents medication errors, and enhances client safety by reducing misinterpretations. Client understanding and data entry ease are secondary benefits.
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring?
- A. Muscle relaxation.
- B. Intake and output.
- C. Widening of the pulse pressure.
- D. Pupil dilation.
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic used to reduce ICP by drawing fluid from brain tissue. Monitoring intake and output is critical to assess its effectiveness and prevent dehydration or electrolyte imbalances. Muscle relaxation, pulse pressure, and pupil dilation are not directly related to mannitol's primary effects.
The nurse is caring for a client in skeletal traction for a femoral fracture. Which assessment should be prioritized?
- A. Skin integrity at pin sites.
- B. Room temperature control.
- C. Frequency of bowel movements.
- D. Client's emotional status.
Correct Answer: A
Rationale: Pin site infections are a common complication in skeletal traction, requiring prioritized assessment.