Nokea
The client is diagnosed with multiple myloma. 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 can cause hemorrhagic cystitis; adequate hydration (e.g., 8 glasses of water) helps prevent this.
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During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
The nurse is seeing a client and her 11-month-old baby in the clinic for a wellness checkup. Which comment by the mother would prompt the nurse to notify the health care provider?
- A. She loves to play peekaboo.
- B. She loves to look at herself in the mirror.
- C. She does not like to be around strangers.
- D. She does not try to crawl when I put her down.
Correct Answer: D
Rationale: Lack of crawling at 11 months may indicate developmental delay, requiring provider evaluation. Other behaviors are age-appropriate.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is:
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Patch the affected eye.
Correct Answer: C
Rationale: Covering both eyes prevents eye movement, reducing further damage.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.