Nokea
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Monitor the client's temperature every 4 hr.
- B. Administer the chemotherapy through a peripheral IV.
- C. Check the IV site for signs of infiltration.
- D. Encourage the client to avoid handwashing.
Correct Answer: C
Rationale: Checking for infiltration prevents extravasation, critical for chemotherapy safety. Temperature monitoring is routine, central lines are preferred, and handwashing is encouraged.
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A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?
- A. Maintain abduction of the client's residual limb with a pillow.
- B. Encourage the client to use the overbed trapeze.
- C. Caution the client to avoid a prone position while in bed.
- D. Keep a loose, absorbent dressing over the client's surgical site.
Correct Answer: B
Rationale: Using an overbed trapeze builds upper body strength, aiding independent repositioning. Abduction, avoiding prone positions, or loose dressings don't directly enhance mobility.
A nurse is caring for a client who has a new prescription for digoxin. Which of the following actions should the nurse take?
- A. Check the client's potassium level.
- B. Administer the medication with a high-fiber meal.
- C. Instruct the client to take the medication at bedtime.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: Digoxin toxicity risks increase with hypokalemia, so potassium monitoring is essential. Fiber meals, bedtime dosing, or routine blood pressure checks aren't specific.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medical health insurance claims
- C. Physical assessment findings
- D. Medications taken prior to admission
Correct Answer: C
Rationale: Physical assessment findings like mobility or pain are critical for a physical therapist to develop a tailored plan. Family history, insurance, or past medications are less relevant.
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide can cause hypokalemia, so potassium levels must be monitored. Sodium, calcium, or magnesium aren't primarily affected.