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The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
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The nurse is contributing to the plan of care for a client with pertussis. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Monitor the client's respiratory effort.
- B. Implement droplet precautions for the client.
- C. Place the client in a room with monitored negative air pressure.
- D. Request a prescription for a cough suppressant for the client.
- E. Offer the client small sips of fluid frequently.
Correct Answer: A, B, E
Rationale: Monitoring respiratory effort (A), droplet precautions (B), and frequent fluids (E) manage pertussis symptoms and transmission. Negative pressure rooms (C) are for airborne diseases, and cough suppressants (D) may worsen mucus clearance.
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: Left ventricular end-diastolic pressure. The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure, assessing the heart's ability to pump effectively.
An adult client has been medicated for elective surgery. The operating room nurse discovers that the consent form for surgery has not been signed. What should the nurse do?
- A. Have the client sign the consent form
- B. Tell the physician that the consent form has not been signed
- C. Have the client's spouse sign the consent form
- D. Continue preparation for surgery because the client has given implied consent
Correct Answer: B
Rationale: Preoperative medications impair judgment, making consent invalid post-administration. Notifying the physician ensures legal and ethical consent is obtained, delaying surgery if needed.
Which of the following toys is the most appropriate for a 2-year old with Tetralogy of Fallot?
- A. A toy horn
- B. A stethoscope
- C. A push-pull toy
- D. A shape sorter
Correct Answer: C
Rationale: A push-pull toy encourages gentle physical activity suitable for a 2-year-old with Tetralogy of Fallot, who may tire easily. A toy horn requires exertion, a stethoscope is not age-appropriate, and a shape sorter is sedentary.
Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.
- A. Dimming the lights at night
- B. Leaving the television on for diversion at night
- C. Opening the window blinds/shades in the morning
- D. Scheduling interventions and activities during the day when possible
- E. Turning off equipment alarms in the client's room at night
Correct Answer: A, C, D
Rationale: Dimming lights (A), opening blinds in the morning (C), and scheduling activities during the day (D) promote circadian rhythms and rest. Leaving the TV on (B) may disrupt sleep, and turning off alarms (E) compromises safety.