Nokea
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's chemotherapy medications. What action by the nurse is most appropriate?
- A. Crush the medications if the client reports difficulty swallowing them.
- B. Give one medication at a time with a full glass of water.
- C. No special precautions are needed for these medications.
- D. Wear personal protective equipment when handling the medications.
Correct Answer: D
Rationale: During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.
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A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important?
- A. Assessing the client's allergies
- B. Ensuring that informed consent is on the chart
- C. Marking the client's bilateral pedal pulses
- D. Reviewing client teaching done previously
Correct Answer: B
Rationale: This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
- A. Assess the client for a headache.
- B. Assist the client by getting out of bed.
- C. Initiate the client to reduce salt intake.
- D. Weigh the client daily before the client eats.
Correct Answer: B
Rationale: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client's risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.
A client has dry, itchy skin after cancer treatment. Which actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply unscented moisturizer to the client's skin.
- B. Apply a steroid cream to affected areas.
- C. Use mild soap for bathing.
- D. Help the client with a hot water bath.
- E. Teach the client to avoid sunlight.
Correct Answer: A,C
Rationale: The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply the client's shoes before getting the client out of bed.
- B. Assist with ambulation.
- C. Shave the client with a safety razor only.
- D. Use a lift sheet to move the client up in bed.
- E. Use the Waterpik on a low setting for oral care.
Correct Answer: A,B,D
Rationale: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, and use a lift sheet when needed to reposition the client. An electric razor should be used instead of a safety razor, and a soft-bristled toothbrush is preferred over a Waterpik for oral care.
A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)
- A. Assist with rinsing the mouth with saline frequently.
- B. Encourage the client to eat room-temperature foods.
- C. Give the client hot liquids to hold in the mouth.
- D. Provide local anesthetic medications to swish and spit.
- E. Remind the client to brush gently after each meal.
Correct Answer: A,B,D,E
Rationale: Mucositis can interfere with nutrition. The nurse can help by assisting with rinsing the mouth frequently with saline, encouraging the client to eat cool or room-temperature foods, providing swish-and-spit anesthetics, and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids should be avoided as they can be painful for the client.