Nokea
The nurse is teaching a 17-year-old client and the client's family about what to expect with high-dose chemotherapy. Which of the following side effects should be included in the teaching plan?
- A. Fever.
- B. Chills.
- C. Tachycardia.
- D. Dyspnea.
Correct Answer: A
Rationale: Fever is a common side effect of high-dose chemotherapy due to neutropenia and increased infection risk, and should be included in the teaching plan.
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The following scenario applies to the next 1 items
The emergency department nurse cares for a child with otitis media
Item 1 of 1
Nurses' Note
Vital Signs
Orders
1815: 10-year-old-male arrives at the emergency department (ED) after reporting a fever, left ear pain, and malaise that started three days ago and has worsened. The client's father reports that he was at a pool party a few days before the symptoms started. The child is alert and fully oriented. Warm to touch and reports that 'it hurts a lot.' The left ear was slightly reddened with no drainage. Peripheral pulses were palpable. Lung sounds were clear. Reports no coughing or other symptoms. The child does not have any medical history. No known allergies. Current on all immunizations. Current weight is 33 kilograms (kg).
The nurse should administer the ceftriaxone in the client's ............................……. to prevent............................……….. The nurse should obtain a prescription for ............................…. cream to apply one hour before the injection to decrease the child's pain.
- A. ventrogluteal
- B. dorsogluteal
- C. Abdomen
- D. nerve damage.
- E. staining of the skin
- F. hydrocortisone
- G. EMLA (lidocaine and prilocaine)
Correct Answer: A,D,G
Rationale: Ceftriaxone should be administered in the ventrogluteal site to avoid nerve damage; EMLA cream reduces pain when applied an hour prior.
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.
Because a client's renal stone was found to be composed of uric acid, a low-purine, alkaline-ash diet was ordered. Incorporation of which of the following food items into the home diet would indicate that the client understands the necessary diet modifications?
- A. Milk, apples, tomatoes, and corn.
- B. Eggs, spinach, dried peas, and gravy.
- C. Salmon, chicken, and asparagus.
- D. Grapes, corn, cereals, and liver.
Correct Answer: A
Rationale: Milk, apples, tomatoes, and corn are low-purine and promote an alkaline-ash diet, suitable for uric acid stone prevention.
A 36-year-old female is complaining of increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. An appropriate nursing intervention would be to instruct the client on the use of:
- A. Vaginal dilators.
- B. Nightly douches.
- C. Water-soluble vaginal lubricants.
- D. Relaxation techniques.
Correct Answer: C
Rationale: Water-soluble vaginal lubricants are effective for managing vaginal dryness caused by chemotherapy-induced ovarian suppression, improving comfort during intercourse.
The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
- A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.
- B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.
- C. Assist the client out of bed to sit upright in a chair for 1 hour.
- D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.
Correct Answer: C
Rationale: Sitting upright in a chair for 1 hour after a bolus tube feeding minimizes aspiration risk by promoting gastric emptying and reducing reflux.