Nokea
A client undergoing chemotherapy tells the nurse, 'I do not want to get out of bed in the morning because I am so tired.' The nursing plan of care should include:
- A. Education on the use of Neupogen (filgrastim).
- B. Individually tailored exercise program.
- C. Weight lifting when not experiencing fatigue.
- D. Bed rest until chemotherapy is completed.
Correct Answer: B
Rationale: An individually tailored exercise program can help combat fatigue, improve energy levels, and enhance quality of life for chemotherapy patients.
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A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
- A. Platelet count.
- B. Prothrombin time (PT).
- C. Activated partial thromboplastin time (aPTT).
- D. International normalized ratio (INR).
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.
The nurse has attended a staff developmental conference on pediatric pain management. Which of the following statements by the nurse would indicate a correct understanding of the teaching?
- A. Patient-controlled analgesia (PCA) can be used as early as age 7.
- B. Lidocaine-adrenaline-tetracaine (LAT) can provide local anesthesia 2 hours after it is applied.
- C. Transdermal fentanyl patch can provide acute pain relief.
- D. Intramuscular delivery of pain medication is preferred for children.
Correct Answer: A
Rationale: PCA can be used in children as young as 7 if they understand the concept. LAT works within 30-60 minutes, fentanyl patches are for chronic pain, and IM injections are avoided in children due to pain and variability.
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
- A. 90 percent of clients have not gained weight.
- B. 75 percent of the clients viewed the educational video.
- C. 80 percent of the clients reported that they are taking their medications.
- D. 5 percent of the clients required hospitalization in the last 90 days.
Correct Answer: A,C,D
Rationale: No weight gain (A), medication adherence (C), and low hospitalization rates (D) indicate effective management of heart failure through monitoring and teaching.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
- A. Biliary system.
- B. Gastrointestinal tract.
- C. Brain and meninges.
- D. Pulmonary system.
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.