Nokea
A client who has Hodgkin's disease receives a weekly IV dose of nitrogen mustard. Which nursing order is most appropriate for this client?
- A. Encourage mouth care with an astringent mouthwash and dental floss after every meal
- B. Encourage organ meats and dried beans and peas
- C. Monitor vital signs daily
- D. Encourage fluid intake to 3000 cc
Correct Answer: D
Rationale: Nitrogen mustard causes bone marrow suppression and nausea; high fluid intake helps flush the drug and prevent dehydration.
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A 68-year-old client was admitted with congestive heart failure, has been digitalized, and is now taking a maintenance dose of digoxin 0.25 mg PO daily. The client is to be discharged soon. Which assessment is of most immediate concern to the nurse?
- A. The client's apical pulse is 66.
- B. The client says that he is nauseous and has no appetite.
- C. The client says that he will take his pill every morning.
- D. The client has lost 8 lb since his admission one week ago.
Correct Answer: B
Rationale: Nausea and anorexia are signs of digoxin toxicity, requiring immediate attention to prevent serious complications.
The nurse is administering a topical ointment to the client's rash on the right leg. Which intervention should the nurse implement first?
- A. Don nonsterile gloves.
- B. Cleanse the client's right leg.
- C. Check the client's armband.
- D. Wash the hands for 15 seconds.
Correct Answer: D
Rationale: Hand washing is the first step to prevent infection, per aseptic technique. Gloves, cleansing, or armband checks follow.
The charge nurse is observing the new graduate administering a fentanyl (Duragesic) patch to a client diagnosed with cancer. Which action by the new graduate requires intervention by the charge nurse?
- A. The new graduate documents the date and time on the patch.
- B. The new graduate removes the patch 24 hours after it is placed on the client.
- C. The new graduate rotates the application site on the client's body.
- D. The new graduate checks the client's name band and date of birth.
Correct Answer: B
Rationale: Fentanyl patches last 72 hours; removing at 24 hours is incorrect and requires intervention. Dating, rotating sites, and ID checks are correct.
The client diagnosed with bipolar disorder has been taking valproic acid (Depakote), an anticonvulsant, for four (4) months. Which assessment data would warrant the medication being discontinued?
- A. The client's eyes are yellow.
- B. The client has mood swings.
- C. The client's BP is 164/94.
- D. The client's serum level is 75 mcg/mL.
Correct Answer: A
Rationale: Yellow eyes suggest hepatotoxicity, a serious valproic acid side effect, warranting discontinuation. Mood swings, hypertension, or normal levels are less critical.
An adult client had an abdominal hysterectomy this morning. Meperidine HCl (Demerol) 75 mg IM q3-4h PRN for pain is ordered. At 9:00 P.M., she complains of lower abdominal pain. She was last medicated at 5:45 P.M. What is the most appropriate initial action for the nurse to take?
- A. Offer her a bed pan and a back rub
- B. Reposition her
- C. Administer meperidine HCl 75 mg IM
- D. Encourage her to perform relaxation and breathing exercises
Correct Answer: C
Rationale: The last dose was over 3 hours ago, within the PRN order. Administering meperidine is appropriate for pain relief.