Nokea
A client has dry, itchy skin after cancer treatment. Which actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply unscented moisturizer to the client's skin.
- B. Apply a steroid cream to affected areas.
- C. Use mild soap for bathing.
- D. Help the client with a hot water bath.
- E. Teach the client to avoid sunlight.
Correct Answer: A,C
Rationale: The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.
You may also like to solve these questions
A client receiving chemotherapy has a white blood cell count of 1000/mm³. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess all mucous membranes every 4 to 8 hours.
- B. Do not allow the client to eat meat or poultry.
- C. Listen to lung sounds and monitor for cough.
- D. Monitor the venous access device appearance with vital signs.
- E. Take and record vital signs every 4 to 8 hours.
Correct Answer: A,C,D,E
Rationale: Per facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.
A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)
- A. Assist with rinsing the mouth with saline frequently.
- B. Encourage the client to eat room-temperature foods.
- C. Give the client hot liquids to hold in the mouth.
- D. Provide local anesthetic medications to swish and spit.
- E. Remind the client to brush gently after each meal.
Correct Answer: A,B,D,E
Rationale: Mucositis can interfere with nutrition. The nurse can help by assisting with rinsing the mouth frequently with saline, encouraging the client to eat cool or room-temperature foods, providing swish-and-spit anesthetics, and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids should be avoided as they can be painful for the client.
A client has a low hemoglobin level. Which medication does the nurse prepare to administer?
- A. Epoetin alfa (Epogen)
- B. Filgrastim (Neupogen)
- C. Mesna (Mesnex)
- D. Oprelvekin (Neumega)
Correct Answer: A
Rationale: The client's hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.
A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important?
- A. Assessing the client's allergies
- B. Ensuring that informed consent is on the chart
- C. Marking the client's bilateral pedal pulses
- D. Reviewing client teaching done previously
Correct Answer: B
Rationale: This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.
A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Ask the family to describe their concerns more fully.
- B. Consult with a social worker, chaplain, or ethics committee.
- C. Explain the client's right to know and ask for their assistance.
- D. Have the unit manager take over the care of this client and family.
- E. Tell the family that this secret will not be kept from the client.
Correct Answer: A,B,C
Rationale: The client's right of autonomy means that the client must be fully informed as to their diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. Explaining the client's right to know while seeking family assistance fosters collaboration.