Nokea
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
- A. Carefully monitor the access site during the administration of the medication.
- B. Hold the medication until an implanted port or central line is established.
- C. Ensure that a chemotherapy-certified nurse is assigned to care for the client.
- D. Call the pharmacy to find out if the prescribed medication has vesicant properties.
Correct Answer: A
Rationale: Step-by-step rationale for the correct answer, A:
1. Monitoring the access site during administration allows for early detection of extravasation.
2. Early detection can prevent serious tissue damage and complications.
3. As Mr. L has a tracheostomy and partial laryngectomy, his airway is compromised, making prevention of extravasation crucial.
4. This action is within the nurse's scope of practice and promotes patient safety.
Summary:
- Choice B is incorrect as delaying treatment can impact Mr. L's health.
- Choice C is not directly related to preventing extravasation.
- Choice D, though important, does not directly address preventing extravasation during administration.
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The nurse cares for a patient who complains of back pain. Which question should the nurse ask to obtain specific information about the back pain?
- A. "Would you like medication for the pain?"
- B. "What have you been doing in the last few days?"
- C. "Do you have a family history of osteoporosis?"
- D. "What do you think caused the back pain?"
Correct Answer: D
Rationale: The correct answer is D because asking "What do you think caused the back pain?" allows the patient to provide specific details about the onset and potential triggers of the pain, aiding in diagnosis and treatment planning. Choice A is incorrect as it focuses on medication rather than gathering information. Choice B is too broad and may not directly address the back pain issue. Choice C is irrelevant to the immediate assessment of the back pain and does not provide specific information about the patient's current condition.
The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.
A client has high blood pressure and needs to learn about a low-sodium diet. Which question if asked by the client would be an indirect request for information?
- A. "How should I prepare food without adding salt?=
- B. "What will I do to make food taste better?=
- C. "What diet changes are needed to control my blood pressure?=
- D. "What foods should I avoid that are high in sodium?=
Correct Answer: B
Rationale: The correct answer is B because the client is indirectly asking for information on how to make food taste better without explicitly mentioning the need for low-sodium options. By inquiring about making food taste better, the client is seeking alternative ways to enhance flavor without salt, which aligns with the goal of following a low-sodium diet. Choices A, C, and D are more direct in addressing specific aspects of a low-sodium diet, such as food preparation without salt, dietary changes for blood pressure control, and identifying high-sodium foods to avoid, respectively.
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
- A. "Are you experiencing any burning with urination?"
- B. "Did you have a bowel movement today or yesterday?"
- C. "Has the medication helped to relieve the nausea?"
- D. "Were you able to sleep soundly the last couple of nights?"
Correct Answer: B
Rationale: The correct answer is B. Docusate is a stool softener commonly used to prevent constipation, which is a common side effect of opioid pain medications. By asking if the patient had a bowel movement today or yesterday, the nurse can evaluate the effectiveness of docusate in facilitating bowel movements. This question directly assesses the expected outcome of the medication.
A: "Are you experiencing any burning with urination?" - This question is more relevant to urinary tract infections, not related to docusate use for constipation.
C: "Has the medication helped to relieve the nausea?" - Docusate is not typically used to relieve nausea, so this question is not relevant to evaluating its effectiveness.
D: "Were you able to sleep soundly the last couple of nights?" - This question is not directly related to the expected outcome of docusate in treating constipation.
The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a client history that will take about 1 or 2 hours to complete. Which clients would the leader recommend that she approach to fulfill her assignment? (Select all that apply.)
- A. Mr. N (non-Hodgkin lymphoma)
- B. Mr. L (tracheostomy and partial laryngectomy)
- C. Mr. B (bladder cancer)
- D. Ms. C (bowel resection and colostomy)
Correct Answer: B
Rationale: The correct answer is B because Mr. L, who has a tracheostomy and partial laryngectomy, will likely require vital signs monitoring and a detailed client history due to his complex respiratory and communication needs. This assignment will provide the student with valuable experience in caring for clients with specialized needs.
Incorrect choices:
A: Mr. N (non-Hodgkin lymphoma) - While Mr. N may require vital signs monitoring, his condition does not necessarily involve complex care needs that would warrant a 1-2 hour history-taking session.
C: Mr. B (bladder cancer) - Vital signs monitoring and history-taking for a client with bladder cancer may not require as much time as the scenario suggests, as the care needs may not be as complex as those of a client with a tracheostomy and laryngectomy.
D: Ms. C (bowel resection and colostomy) - While Ms. C may require vital signs monitoring and history-taking