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A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
- A. Assess the client for a headache.
- B. Assist the client by getting out of bed.
- C. Initiate the client to reduce salt intake.
- D. Weigh the client daily before the client eats.
Correct Answer: B
Rationale: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client's risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.
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A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Reassuring clients that this change is temporary
- B. Referring clients to a reputable wig shop
- C. Teaching measures to prevent scalp injury
- D. Providing emotional support for body image changes
Correct Answer: D
Rationale: All actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site every hour
- B. Educating the client on side effects
- C. Monitoring the client for nausea
- D. Providing warm packs for comfort
Correct Answer: A
Rationale: Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or more frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports the IV site is painful, this is not the most appropriate action.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply the client's shoes before getting the client out of bed.
- B. Assist with ambulation.
- C. Shave the client with a safety razor only.
- D. Use a lift sheet to move the client up in bed.
- E. Use the Waterpik on a low setting for oral care.
Correct Answer: A,B,D
Rationale: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, and use a lift sheet when needed to reposition the client. An electric razor should be used instead of a safety razor, and a soft-bristled toothbrush is preferred over a Waterpik for oral care.
Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first?
- A. Client with dry, itchy, peeling skin
- B. Client with a serum calcium of 9.2 mg/dL
- C. Client with a serum potassium of 2.8 mg/dL
- D. Client with a weight gain of 6.6 pounds (1.1 kg) in 1 day
Correct Answer: C
Rationale: TKIs can cause electrolyte imbalances. A potassium level of 2.8 mg/dL is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. The calcium level is normal, and the weight gain, while concerning, is less critical than the low potassium level.
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.