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A client receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the nurse's best intervention to manage these symptoms?
- A. Offer frequent, small meals
- B. Administer antiemetics before meals
- C. Encourage the client to eat a high-fat diet
- D. Provide the client with cold, carbonated beverages
Correct Answer: B
Rationale: Administering antiemetics before meals is the best intervention to manage nausea and vomiting in clients receiving chemotherapy. This proactive approach helps control symptoms by preventing nausea from occurring, rather than waiting to treat it once symptoms have already started. Offering frequent, small meals (choice A) may worsen symptoms in some cases due to increased stomach activity. Encouraging a high-fat diet (choice C) can be difficult for nauseated clients and may not alleviate symptoms. Providing cold, carbonated beverages (choice D) could exacerbate nausea further due to the temperature and carbonation.
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A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?
- A. Check for kinks in the chest tube tubing.
- B. Assess the client's lung sounds.
- C. Elevate the head of the bed to 30 degrees.
- D. Prepare for chest tube replacement.
Correct Answer: C
Rationale: The correct first action for a client with a chest tube experiencing increased shortness of breath is to elevate the head of the bed to 30 degrees. This position promotes lung expansion, improves oxygenation, and can help relieve shortness of breath. Checking for kinks in the chest tube tubing would be important but not the first action in this situation. Assessing the client's lung sounds is also important but not the initial priority. Preparing for chest tube replacement is not indicated based solely on the client's complaint of increased shortness of breath.
A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting milk products arrives at the clinic accompanied by the parents. Which type of testing should the nurse educate the toddler's family about?
- A. Complete blood count
- B. Lactose tolerance test
- C. Skin allergy testing
- D. Serum immunoglobulin E
Correct Answer: D
Rationale: The correct answer is D, Serum immunoglobulin E (IgE) testing. This test can help diagnose food allergies, including milk protein allergies, in toddlers presenting with symptoms like skin rashes, hives, abdominal pain, and vomiting after consuming milk products. Skin allergy testing is used for allergies but may not be suitable for this age group due to developmental factors. Lactose intolerance, which is different from a milk allergy, is assessed through a lactose tolerance test, not IgE testing. A complete blood count (CBC) would not provide specific information related to food allergies.
A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?
- A. Report orange-colored urine as a sign of kidney dysfunction.
- B. Expect red-orange discoloration of urine as a harmless side effect.
- C. Monitor for signs of liver toxicity.
- D. Call the healthcare provider if vision changes occur.
Correct Answer: B
Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.
A client with Addison's disease becomes confused and weak. What is the nurse's first action?
- A. Administer a dose of hydrocortisone immediately.
- B. Check the client's electrolyte levels.
- C. Administer a dose of normal saline.
- D. Measure the client's blood pressure in both arms.
Correct Answer: A
Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.
A client with hypothyroidism is experiencing severe lethargy and cold intolerance. What action should the nurse take?
- A. Increase the dose of levothyroxine.
- B. Administer a PRN dose of antipyretic medication.
- C. Provide a warm blanket and increase the room temperature.
- D. Increase the client's fluid intake to avoid dehydration.
Correct Answer: A
Rationale: The correct answer is to increase the dose of levothyroxine. In hypothyroidism, the body does not produce enough thyroid hormone, leading to symptoms like lethargy and cold intolerance. Increasing the dose of levothyroxine, which is a synthetic thyroid hormone replacement, helps correct the deficiency and alleviates the symptoms. Choice B, administering antipyretic medication, is incorrect as antipyretics are used to reduce fever, not treat hypothyroidism symptoms. Choice C, providing a warm blanket and increasing room temperature, may provide temporary comfort but does not address the underlying hormonal deficiency. Choice D, increasing fluid intake, is important for overall health but does not directly address the symptoms of hypothyroidism.