Nokea
A patient in the outpatient oncology clinic complains of fatigue after receiving chemotherapy. Which initial nursing intervention will be most appropriate?
- A. Assess for other factors contributing to her fatigue, such as trouble sleeping.
- B. Encourage a high-protein, high-calorie diet, and design it with the patient.
- C. Refer the patient to a physical therapist to develop a strenuous exercise program.
- D. Encourage the patient to sleep as much as possible during the day to ease fatigue.
Correct Answer: A
Rationale: Fatigue is a common side effect of chemotherapy and can be caused by various factors, including anemia, poor nutrition, sleep disturbances, or psychological stress. The nurse's first step should be to assess for underlying causes of fatigue, such as trouble sleeping, anemia, or depression. Once the cause is identified, appropriate interventions can be implemented, such as dietary changes, sleep hygiene strategies, or treatment for anemia. Encouraging excessive daytime sleep or strenuous exercise without assessment may worsen fatigue or lead to other complications.
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A patient is receiving an IV infusion of heparin and was started on warfarin therapy the night
- A. Which statement is most correct?
- B. The patient is receiving a double dose of anticoagulants.
- C. The heparin therapy was ineffective, so the warfarin was starte
- D. The heparin provides anticoagulation until therapeutic levels of warfarin are reache
Correct Answer: D
Rationale: The correct statement is that the heparin provides anticoagulation until therapeutic levels of warfarin are reached. Heparin and warfarin are both anticoagulants but work in different ways. Heparin acts quickly to prevent blood clot formation while warfarin takes several days to reach its full effect. Therefore, heparin is often used initially to provide immediate anticoagulation while waiting for the warfarin to reach therapeutic levels. This dual therapy is common in clinical practice to ensure continuous anticoagulation.
Which nursing diagnosis is appropriate for a patient receiving antidysrhythmics?
- A. Risk for infection
- B. Deficient knowledge
- C. Deficient fluid volume
- D. Urinary retention
Correct Answer: C
Rationale: The appropriate nursing diagnosis for a patient receiving antidysrhythmics would be Deficient fluid volume. Antidysrhythmics can have side effects such as electrolyte imbalances, which can lead to fluid volume deficit. Monitoring the patient's fluid intake and output is crucial to prevent dehydration and maintain proper electrolyte balance. Therefore, identifying Deficient fluid volume as a nursing diagnosis allows for appropriate interventions to be implemented to address and prevent this potential complication.
The nurse observes a short period of asystole on the cardiac monitor that resolves spontaneously immediately after administering adenosine IV to a patient who was experiencing paroxysmal supraventricular tachycardia. Which initial action is the most appropriate for the nurse?
- A. Call a code to report a cardiac arrest.
- B. Prepare epinephrine and atropine for intravenous administration.
- C. Initiate cardiopulmonary resuscitation (CPR).
- D. Closely observe the patient and the cardiac monitor.
Correct Answer: D
Rationale: Adenosine is used to treat paroxysmal supraventricular tachycardia (PSVT) by temporarily blocking AV node conduction, which can cause a brief period of asystole. This is an expected effect and typically resolves spontaneously. The nurse should closely monitor the patient and the cardiac monitor for the return of a normal rhythm. Calling a code (A), preparing epinephrine and atropine (B), or initiating CPR (C) is unnecessary unless the asystole persists or the patient becomes unstable.
What is the common side effect that is normal with the initial therapy of Nitroglycerine due to increased vasodilation?
- A. Abdominal cramps
- B. Calf
- C. Headache
- D. Blurred vision
Correct Answer: C
Rationale: The most common side effect that is normal with the initial therapy of Nitroglycerine due to increased vasodilation is a headache. Nitroglycerine causes vasodilation of blood vessels, including the blood vessels in the head and brain. This can lead to headaches as a result of the increased blood flow and changes in blood vessel diameter. Headaches caused by Nitroglycerine are usually mild and transient. It is important to monitor patients for this expected side effect and educate them about it to ensure compliance with the medication regimen.
A patient with a history of HF presents to the emergency department with difficulty breathing, cough, and edema of the lower extremities. The nurse anticipates administration of which type of medication?
- A. Positive chronotrope
- B. Negative chronotrope
- C. Positive inotrope
- D. Negative inotrope
Correct Answer: C
Rationale: In the scenario described, the patient with a history of heart failure (HF) is presenting with symptoms of difficulty breathing, cough, and edema of the lower extremities. These signs and symptoms suggest acute decompensated heart failure (ADHF), which is characterized by a decrease in cardiac output and inadequate tissue perfusion. In this situation, the nurse would anticipate the administration of a positive inotrope medication.