Nokea
A nurse is floated to oncology from the postsurgical floor. The assigned client is almost finished with an infusion of doxorubicin for breast cancer. The floated nurse is not chemotherapy certified. Which nursing action is the priority in this situation?
- A. assess the client's pain
- B. ask another nurse about side effects of the drug
- C. assess the IV site, including the date on the tubing and IV site
- D. inform the charge nurse that she is not chemotherapy certified and ask for another assignment
Correct Answer: D
Rationale: The priority is to inform the charge nurse of the lack of chemotherapy certification, as doxorubicin requires specialized handling and monitoring.
You may also like to solve these questions
A 78-year-old client with a history of diabetes mellitus type 2, GERD, and hypertension is hospitalized with pneumonia and rings the call bell at 11 PM, complaining of being unable to sleep and having 'indigestion' and 'heartburn.' Which of the following initial interventions is most indicated?
- A. Administer antacid per prn order.
- B. Administer acetaminophen per prn order.
- C. Administer hypnotic per prn order.
- D. Assess cardiac and respiratory status.
Correct Answer: D
Rationale: In an elderly client with comorbidities, indigestion and heartburn may indicate a cardiac event, so assessing cardiac and respiratory status (D) is the priority. Administering medications (A, B, C) is secondary.
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
- A. allowing clients in a substance abuse facility to be interviewed by the media
- B. violating the HIPAA need to know rule
- C. releasing information about a minor without parental consent
- D. There is no violation.
Correct Answer: B
Rationale: The nurse violated HIPAA by allowing the filming of other clients without their consent, as this discloses protected health information (PHI) without authorization.
The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.
A child was exposed to the hepatitis A virus, became ill, and made a full recovery 2 years ago. The child is now immune to the hepatitis A virus and will likely be protected for the rest of her life. This type of immunity is referred to as
- A. active artificial immunity.
- B. naturally acquired active immunity.
- C. artificially acquired passive immunity.
- D. naturally acquired passive immunity.
Correct Answer: B
Rationale: Recovery from hepatitis A infection confers lifelong immunity via naturally acquired active immunity, as the body produces its own antibodies.