Nokea
The nurse is preparing the client for a bone marrow biopsy of the iliac crest. Place the nurse’s actions in order of priority.
- A. Premedicate with lorazepam
- B. Obtain a signed informed consent
- C. Position prone and provide emotional support
- D. Verify that the HCP has explained the procedure
- E. Check for signs of bleeding every 2 hours for 24 hours
- F. Teach what may be expected during the procedure
Correct Answer: D, F, B, A, C, E:
Rationale: Verify that the HCP has explained the procedure. The HCP should include the purpose, intended outcomes, and potential complications. F. Teach what may be expected during the procedure, including that pressure or discomfort may be experienced. B. Obtain a signed informed consent. This is obtained only after the HCP has met with the client and teaching is completed. A. Premedicate with lorazepam (Ativan). Midazolam (Versed) is another option for sedation. A local anesthetic is used at the site, and some clients may not need sedation. C. Position prone and provide emotional support. The client should be prone because the iliac crest is the site being used for this biopsy, but the position will vary with the site. Holding the client’s hand and using guided imagery help support the client. E. Check for signs of bleeding every 2 hours for 24 hours. A pressure dressing is applied by the HCP after the procedure. Ice can be applied to reduce bruising and for comfort.
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The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation?
- A. The client with an abdominal peritoneal resection who has a colostomy.
- B. The client diagnosed with pneumonia who has acute respiratory distress syndrome.
- C. The client with a head injury developing disseminated intravascular coagulation.
- D. The client admitted with a gunshot wound who has an H&H of 7 and 22.
Correct Answer: A
Rationale: Colostomy care (A) is stable and suitable for a new graduate. ARDS (B), DIC (C), and severe anemia (D) are critical, requiring experienced care.
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
- A. Give through an IV catheter in a large peripheral vein if infusing in less than 60 minutes.
- B. Check patency every 5 to 10 minutes during infusion and ask about IV site discomfort.
- C. Check the IV pump and alarm for indications of an infiltration of the medication.
- D. Check for blood return in a central venous catheter prior to administration of the vesicant.
- E. Use small-gauged syringes with small barrels when flushing any access devices with saline.
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
Following morning shift report, the nurse identifies care needs for four clients. Which client should be the nurse’s priority?
- A. The client with lung cancer who is to receive ondansetron 8 mg IV 30 minutes prior to chemotherapy
- B. The client with an absolute neutrophil count of 98/mm3 who needs to be placed on neutropenic precautions
- C. The client who is stable but has breast cancer and is scheduled for external beam radiation in 15 minutes
- D. The client with stomatitis from radiation for tonsillar cancer who is to receive a gastrostomy tube feeding
Correct Answer: B
Rationale: A. No time is noted for the administration of ondansetron (Zofran) prior to chemotherapy treatment; this client is not the nurse’s priority. B. The client with neutropenia should be the nurse’s priority. If seen first, microorganisms from other clients would be less likely to be transmitted to the client. This client is at risk for infection and severe sepsis because the absolute neutrophil count is less than 1001mm3 (normal = 1500 to 8000/mm3). C. This client is stable; another person can take this client to radiation therapy, and the nurse’s assessment can wait until the client returns. D. The tube feeding can be initiated after the needs of the most critical client are met.
In which order should the nurse address the assessment findings for the client who has undergone a total laryngectomy? Place the findings in the order of priority.
- A. Copious oral secretions and nasal mucus draining from the nose
- B. Restless and has a mucus plug in the tracheostomy
- C. NG tube used for intermittent feedings pulled halfway out
- D. Oozing serosanguineous drainage around the tracheostomy tube and dressing saturated
Correct Answer: B, A, D, C
Rationale: . Restless and has a mucus plug in the tracheostomy is priority requiring immediate attention due to the negative impact on air exchange. The client needs immediate suctioning. A. Copious oral secretions and nasal mucus draining from the nose should be next. After a total laryngectomy the mouth does not communicate with the trachea, so copious oral secretions and nasal drainage would not influence air exchange, but these create a source of discomfort for the client. D. Oozing serosanguineous drainage around the tracheostomy tube and saturated dressing should be addressed third. Changing the dressing now would allow the nurse to inspect the site and ensure tube patency. C. NG tube used for intermittent feedings pulled halfway out can be addressed last. There is no indication that a tube feeding is infusing. The HCP should be contacted to reinsert the NG tube to prevent disruption of the suture line in the esophagus.
The nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to the client with prostate cancer. Which client is a candidate for “watchful waiting”?
- A. 50-year-old with prostate cancer that has metastasized to the bone
- B. 75-year-old expected to live 5 years and has low-grade disease
- C. 45-year-old who has extension of the tumor outside of the prostate
- D. 59-year-old who is asymptomatic with an elevated prostate-specific antigen
Correct Answer: B
Rationale: A. The client with prostate cancer that has metastasized to the bone generally requires aggressive therapy. B. The client is a candidate for “watchful waiting” when older than age 70 with a life expectancy of less than 10 years and with low-grade disease. C. The client with extension of the tumor outside of the prostate generally requires aggressive therapy. D. The client who is asymptomatic with an elevated prostate-specific antigen generally requires aggressive therapy.