Nokea
The nurse is caring for a client receiving chemotherapy. Which precaution is most important?
- A. Use standard precautions.
- B. Wear a gown and gloves.
- C. Place the client in isolation.
- D. Monitor for fever.
Correct Answer: D
Rationale: Monitoring for fever is critical, as chemotherapy increases infection risk due to immunosuppression.
You may also like to solve these questions
A client with a diagnosis of hyperthyroidism is prescribed propylthiouracil (PTU). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Propylthiouracil can cause agranulocytosis, requiring monitoring of white blood cell counts.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.
A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has ordered a 250-mL bolus of normal saline over 1 hour to replace blood loss. The I.V. solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/hour. The nurse should: Select all that apply.
- A. Increase the I.V. infusion rate to 250 mL/hour for 1 hour.
- B. Add 250 mL of normal saline to the current infusion bag and continue at 100 mL/hour.
- C. Connect a 250-mL bag of normal saline to the Y-connection and calculate to infuse over 1 hour.
- D. Contact the physician regarding continuation of the primary I.V. infusion during the bolus infusion.
- E. Administer the normal saline bolus via an I.V. infusion pump.
Correct Answer: C,E
Rationale: A separate 250-mL bag via Y-connection and infusion pump ensures accurate delivery of the bolus without altering the primary infusion.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?
- A. Institute droplet precautions.
- B. Obtain the child's vital signs.
- C. Ask the parent about medication allergies.
- D. Inquire about the health of siblings at home.
Correct Answer: A
Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.