Nokea
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.
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The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
- A. Risk for ineffective breathing pattern
- B. Risk for imbalanced body temperature
- C. Risk for decreased cerebral tissue perfusion
- D. Activity intolerance
Correct Answer: B
Rationale: Thyroid crisis (thyroid storm) causes hyperthermia, making imbalanced body temperature the priority due to the risk of life-threatening hypermetabolic complications.
The nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following findings would indicate magnesium toxicity?
- A. Respiratory rate of 18 breaths per minute.
- B. Deep tendon reflexes absent.
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 140/90 mmHg.
Correct Answer: B
Rationale: absent deep tendon reflexes are a sign of magnesium toxicity, requiring immediate intervention
The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid carbonated beverages
- D. Increase his intake of citrus fruits
Correct Answer: C
Rationale: Carbonated beverages can increase stomach pressure and worsen GERD symptoms by promoting acid reflux.
The floor nurse sees a new order in a client's chart for levothyroxine (Synthroid) 125 mcg PO every day. The pharmacy sends up Synthroid 0.1 mg tablets. How many tablets should the nurse administer? Calculate and fill in the blank.
Correct Answer: 1.25
Rationale: 125 mcg = 0.125 mg. 0.125 mg ÷ 0.1 mg/tablet = 1.25 tablets.
The nurse is caring for a 7-year-old child with constipation. The child's mother asks the nurse what she can do to help prevent another episode. What information would the nurse include in her response?
- A. Give enemas until the child runs clear.
- B. Give laxatives daily on a regular basis.
- C. Provide lots of milk and sugary foods to promote defecation.
- D. Have the child sit on the toilet for 5 to 10 minutes about 20 to 30 minutes after meals to encourage defecation.
Correct Answer: D
Rationale: Encouraging regular toilet habits after meals promotes bowel regularity without relying on invasive or inappropriate measures like enemas or excessive milk.