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A client receiving chemotherapy reports severe nausea. What should the nurse implement first?
- A. Administer an antiemetic as prescribed.
- B. Offer the client small, frequent meals.
- C. Provide the client with crackers and water.
- D. Encourage the client to eat a bland diet.
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.
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A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?
- A. Provide emotional support
- B. Monitor daily weight
- C. Encourage small frequent meals
- D. Initiate prescribed intravenous fluids
Correct Answer: D
Rationale: Hyperemesis gravidarum, characterized by severe nausea and vomiting, leads to dehydration and electrolyte imbalances. The priority intervention is initiating IV fluids to correct these imbalances. Providing emotional support is important for the client's well-being, but addressing fluid and electrolyte imbalances takes precedence. Monitoring daily weight and encouraging small frequent meals are beneficial interventions but are not the priority when managing hyperemesis gravidarum.
The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct Answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.
The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
- A. Question the client about the frequency of falls.
- B. Request the client to lie still during the assessment.
- C. Ask how often episodes of sundowning are experienced.
- D. Assist the client with values clarification about end-of-life care.
Correct Answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.
While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 episodes of incontinent diarrhea
- D. An 80-year-old ambulatory diabetic client
Correct Answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.
While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?
- A. Apply a pressure dressing around the chest tube site.
- B. Administer an oral antihistamine.
- C. Assess for allergies to topical cleaning agents.
- D. Measure the area of swelling and crackling.
Correct Answer: D
Rationale: When a nurse observes crepitus around a chest tube site, it could indicate subcutaneous emphysema, a potentially serious condition where air gets trapped under the skin. Measuring the area of swelling and crackling is important as it helps monitor the progression of subcutaneous emphysema. Applying a pressure dressing (choice A) might not address the underlying cause and could potentially worsen the condition. Administering an oral antihistamine (choice B) is not indicated for crepitus at a chest tube site. Assessing for allergies to topical cleaning agents (choice C) is important but not the immediate priority when crepitus is observed.