Nokea
The nurse is caring for a client with leukemia who has received the drug (daunorubicin) Cerubidine. Which of the following common side effects would cause the most concern?
- A. Nausea
- B. Vomiting
- C. Cardiotoxicity
- D. Alopecia
Correct Answer: C
Rationale: Daunorubicin is known for cardiotoxicity, which can lead to heart failure and is life-threatening, making it the most concerning side effect. Nausea, vomiting, and alopecia are common but less severe.
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The home health nurse is planning for the day's visits. Which client should be seen first?
- A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
- B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
- C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
- D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct Answer: B
Rationale: The 5-month-old with recent pneumonia is at high risk for complications, prioritizing their assessment.
Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- A. Thiamine
- B. Niacin
- C. Pyridoxine
- D. Riboflavin
Correct Answer: C
Rationale: Pyridoxine (vitamin B6) is given with isoniazid to prevent peripheral neuropathy, a potential side effect of the medication.
The nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. Before administering chemotherapy, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Administering an antiemetic before chemotherapy prevents nausea and vomiting, common side effects of these drugs.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.
When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.