Nokea
The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
- A. Consume foods and liquids at room temperature.
- B. Drink a large amount of fluid with meals.
- C. Consume foods without aromas
- D. Eat smaller portion sizes throughout the day.
- E. Delay taking the prescribed antiemetic until the nausea is severe.
Correct Answer: A,C,D
Rationale: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.
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The nurse enters a client's room who is found on the ground. The nurse should perform which initial action?
- A. Assess the client's level of consciousness
- B. Examine the client for injuries
- C. Call the rapid response team (RRT)
- D. Palpate the client's carotid pulse
Correct Answer: A
Rationale: Assessing the level of consciousness is the initial action to determine the client's neurological status and guide further interventions after a fall.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
The following scenario applies to the next 1 items
The nurse cares for a client on the oncology floor
Item 1 of 1
Admission Note
Physician Orders
The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102°F (38.8°C). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.
The nurse recognizes that this client is at increased risk for developing ………………… therefore, the nurse should implement neutropenic precautions which involves …………………. Considering the client has a fever, the nurse anticipates an order for ……………
- A. systemic infection
- B. chronic renal failure
- C. washing hands frequently.
- D. wearing sterile gloves for client care.
- E. performing frequent oral care.
- F. 24-hour urine collection.
- G. collecting blood cultures.
Correct Answer: A,C,G
Rationale: Neutropenia increases systemic infection risk, requiring frequent handwashing and blood cultures for fever evaluation.
The nurse is caring for a client who is immediately postoperative following a colon resection with the placement of a colostomy. Which of the following client problems are of greatest concern?
- A. Infection
- B. Thermoregulation
- C. Hemorrhage
- D. Altered body image
Correct Answer: C
Rationale: Hemorrhage is the greatest concern immediately post-colon resection due to the risk of significant blood loss from the surgical site, which can be life-threatening. Infection, thermoregulation, and altered body image are important but less immediate.