Nokea
A client is receiving chemotherapy and reports nausea. The nurse should administer which of the following medications as prescribed?
- A. Ondansetron (Zofran).
- B. Diphenhydramine (Benadryl).
- C. Acetaminophen (Tylenol).
- D. Ibuprofen (Advil).
Correct Answer: A
Rationale: Ondansetron is an antiemetic commonly used to manage chemotherapy-induced nausea.
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An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
Which of the following correctly describes Medicaid?
- A. A program designed to assist ill, low-income older adults.
- B. A federal insurance program for pregnant women.
- C. A joint federal-state program for low-income persons.
- D. A program administered by health maintenance organizations.
Correct Answer: C
Rationale: Medicaid is a joint federal-state program providing healthcare coverage for low-income individuals, including children, pregnant women, and the elderly.
Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
- A. Exclude pregnant visitors from the client's room.
- B. Place the client in a negative pressure room.
- C. Have all visitors wear protective masks and boots.
- D. All of the above
Correct Answer: A
Rationale: Brachytherapy involves internal radiation, posing a risk to pregnant individuals due to radiation exposure. Excluding pregnant visitors minimizes this risk.
A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, 'My 6-year-old, Kevin, is starting to act just like his father. I just don't know how to handle this.' Which response by the nurse is most appropriate?
- A. You'll have to limit Kevin's contact with his father.'
- B. Counseling for Kevin would be helpful.'
- C. Most boys outgrow these behaviors.'
- D. Setting limits on his behavior is all you need to do now.'
Correct Answer: B
Rationale: Counseling can help address behavioral issues potentially stemming from trauma or modeling, providing professional support for the child.
The nurse is providing care to the client who has received medication therapy with tissue plasminogen activator. Which item should the nurse have available for use as part of standard nursing care for this client?
- A. Flashlight
- B. Pulse oximeter
- C. Suction equipment
- D. Occult blood test strips
Correct Answer: D
Rationale: Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli caused by thrombus. A frequent and potentially adverse effect of therapy is bleeding. The nurse monitors for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood test strips to monitor for occult blood in the urine, stool, or nasogastric drainage. A flashlight may be used for pupil assessment as part of the neurological exam in the client who is neurologically impaired. Pulse oximeter and suction equipment would be needed if the client had evidence of respiratory problems.