Nokea
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Check the IV site for redness or swelling.
- B. Administer the chemotherapy through a peripheral IV line.
- C. Monitor the client's blood pressure every 4 hr.
- D. Instruct the client to avoid drinking water during infusion.
Correct Answer: A
Rationale: Checking for redness or swelling detects extravasation early, critical for chemotherapy safety. Central lines are preferred, blood pressure checks are routine, and hydration is encouraged.
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A nurse is reinforcing teaching with a client who has a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might experience dizziness when standing up.
- C. You need to limit your potassium intake.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Hydrochlorothiazide can cause orthostatic hypotension, leading to dizziness. It's taken in the morning, potassium may need supplementation, and stopping risks rebound hypertension.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following findings should the nurse report to the provider?
- A. The client reports mild fatigue.
- B. The client's IV site is cool and swollen.
- C. The client's urine output is 200 mL over 4 hr.
- D. The client's temperature is 37.2°C (99°F).
Correct Answer: B
Rationale: A cool, swollen IV site suggests extravasation, a chemotherapy emergency requiring immediate reporting. Fatigue, urine output, and mild fever are less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for enoxaparin. The nurse should identify which of the following over-the-counter products as unsafe for use with enoxaparin.
- A. Cimetidine
- B. Docusate
- C. Calcium supplement
- D. Naproxen
Correct Answer: D
Rationale: Naproxen, an NSAID, increases bleeding risk with enoxaparin, an anticoagulant. Cimetidine, docusate, and calcium supplements don't pose significant interaction risks.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 4 hr.
- B. Flush the tube with water every 12 hr.
- C. Position the client supine during feeding.
- D. Change the feeding bag every 48 hr.
Correct Answer: A
Rationale: Checking residual volume every 4 hours assesses tolerance, preventing aspiration. Flushing is more frequent, supine positioning risks aspiration, and bags change every 24 hours.