Nokea
A client is receiving vincristine (Oncovin). Client teaching by the nurse should include instructions on:
- A. Use of loperamide (Imodium).
- B. Fluid restriction.
- C. Low fiber, bland diet.
- D. Bowel regimen.
Correct Answer: D
Rationale: Vincristine commonly causes constipation due to neurotoxicity. A bowel regimen (e.g., stool softeners, laxatives) is essential to prevent and manage this side effect.
You may also like to solve these questions
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
- A. Assess breath sounds.
- B. Remove the catheter.
- C. Insert a peripheral I.V.
- D. Reposition the client.
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.
On admission to same-day surgery, the nurse reviews the chart to verify the client's identification documentation. Which of the following is most important?
- A. Admitting record.
- B. Addressograph labels.
- C. Identification bracelet.
- D. Location of family.
Correct Answer: C
Rationale: The identification bracelet is the most reliable method to verify client identity, ensuring safety and preventing errors in same-day surgery.
The nurse is checking the laboratory results on a 52-year-old client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed?
- A. Blood glucose.
- B. Total cholesterol.
- C. Hemoglobin.
- D. Low-density lipoprotein (LDL) cholesterol.
Correct Answer: A
Rationale: Elevated blood glucose in type 1 diabetes indicates poor glycemic control, requiring immediate management to prevent complications like ketoacidosis.
The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize
After the initial phase of the burn injury, the client's plan of care will focus primarily on:
- A. Helping the client maintain a positive selfconcept.
- B. Promoting hygiene.
- C. Everything infection.
- D. Educating the client regarding care of the skin grafts.
Correct Answer: C
Rationale: Infection prevention is critical in the acute phase of burn care, as burns compromise the skin's barrier, increasing infection risk. Other options are secondary priorities.