Nokea
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
- A. "Walk about a mile a day to prevent calcium loss."?
- B. "Increase the fiber in your diet."?
- C. "Report nausea to the doctor immediately."?
- D. "Drink at least eight large glasses of water a day."?
Correct Answer: D
Rationale: Cyclophosphamide (Cytoxan) can cause hemorrhagic cystitis, a condition characterized by inflammation of the bladder wall leading to bleeding. To prevent this complication, the client should drink at least eight glasses of water a day. Walking to prevent calcium loss (choice A) and increasing fiber intake (choice B) are not directly related to the side effects of Cytoxan, making them unnecessary instructions in this case. While nausea is a common side effect of chemotherapy, the immediate reporting of nausea to the doctor (choice C) is important but not specifically related to the use of Cytoxan in this scenario.
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A twenty-one-year-old man suffered a concussion, and the MD ordered an MRI. The patient asks, 'Will they allow me to sit up during the MRI?' The correct response by the nurse should be:
- A. "I will have to talk to the doctor about letting you sit upright during the test."?
- B. "You will be positioned in the reverse Trendelenburg position to maximize the view of the brain."?
- C. "The radiologist will let you know."?
- D. "You will have to lie down on your back during the test."?
Correct Answer: D
Rationale: The correct answer is to inform the patient that they will have to lie down on their back during the MRI. This positioning is necessary for the scan to obtain accurate images of the brain. Choice A is incorrect because the decision on the positioning during the MRI is typically determined by the imaging protocol and not subject to negotiation during the test. Choice B is incorrect as the reverse Trendelenburg position is not commonly used during MRI scans. Choice C is incorrect because the radiologist does not usually make decisions on patient positioning during the MRI; it is predetermined by the imaging requirements.
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client's tongue
- D. Checks the client's ability to clench the teeth
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:
- A. 100 ml per hour for one hour.
- B. 60 ml per hour for one-half hour
- C. 120 ml per hour for one hour.
- D. 50 ml per hour for one hour.
Correct Answer: A
Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?
- A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
- B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. Return to their own unit and not disclose that confidential information has been overheard.
- D. Ignore the situation.
Correct Answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.
Why is the intravenous route potentially the most dangerous route of drug administration?
- A. IV infiltration may occur.
- B. it allows for rapid administration of a drug.
- C. rapid administration of a drug can lead to toxicity
- D. it is the most commonly used route in hospitals.
Correct Answer: C
Rationale: The correct answer is C: rapid administration of a drug can lead to toxicity. When a drug is administered intravenously, it has 100% bioavailability, entering the bloodstream immediately and increasing the risk of toxicity if not carefully monitored. While IV infiltration (choice A) can cause tissue damage, it is not typically life-threatening. Choice B is incorrect as the speed of administration is not the primary reason for the danger; it is the immediate and full dose reaching the bloodstream. Choice D is incorrect as the popularity of the route does not inherently make it more dangerous.