Nokea
The following scenario applies to the next 1 items
The nurse cares for a client on the oncology floor
Item 1 of 1
Admission Note
Physician Orders
The client was admitted for observation after reporting increasing fatigue, dyspnea, malaise, and a fever of 102°F (38.8°C). The client is currently being treated with doxorubicin for uterine sarcoma. The initial diagnostic testing revealed pneumonia and neutropenia.
The nurse recognizes that this client is at increased risk for developing ………………… therefore, the nurse should implement neutropenic precautions which involves …………………. Considering the client has a fever, the nurse anticipates an order for ……………
- A. systemic infection
- B. chronic renal failure
- C. washing hands frequently.
- D. wearing sterile gloves for client care.
- E. performing frequent oral care.
- F. 24-hour urine collection.
- G. collecting blood cultures.
Correct Answer: A,C,G
Rationale: Neutropenia increases systemic infection risk, requiring frequent handwashing and blood cultures for fever evaluation.
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The nurse is caring for a client who has nausea related to prescribed chemotherapy treatments. The nurse should recommend that the client. Select all that apply.
- A. Consume foods and liquids at room temperature.
- B. Drink a large amount of fluid with meals.
- C. Consume foods without aromas
- D. Eat smaller portion sizes throughout the day.
- E. Delay taking the prescribed antiemetic until the nausea is severe.
Correct Answer: A,C,D
Rationale: Room-temperature foods, low-aroma foods, and smaller portions reduce nausea. Large fluid intake with meals worsens nausea, and antiemetics should be taken proactively.
The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up?
- A. I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection
- B. I will need to take deep breaths and cough hourly
- C. I will have to attend physical therapy sessions following my surgery
- D. I will be prescribed an anticoagulant and need to take it with a sip of water before the surgery
Correct Answer: D
Rationale: Taking an anticoagulant with a sip of water before surgery is incorrect, as clients are typically NPO, and anticoagulants like enoxaparin are administered post-operatively to prevent thromboembolism. The other statements are correct regarding infection prevention, respiratory exercises, and physical therapy.
Which of the following must NOT be included in an incident or accident form or report?
- A. The name of the person completing the report.
- B. The name of the client and if anyone was injured.
- C. The location of the incident or accident.
- D. An explanation of what may have led to the incident.
Correct Answer: NONE
Rationale: All listed elements are typically required in an incident report to ensure accurate documentation and follow-up.
Your client is reluctant to take a necessary dose of narcotic analgesic for severe pain. The client states, 'I do not want to become a druggie.' How would you respond to this client's comment?
- A. That is ridiculous. Nobody gets addicted to narcotics when they do not have a prior history of drug abuse.
- B. The possible complications of unrelieved pain greatly outweigh the risk of addiction which is very low when a person has no prior history of drug abuse.
- C. A lot of people prefer to be brave and stick it out so you are not alone.
- D. You have a right to refuse any and all treatments, so just do without it.
Correct Answer: B
Rationale: Addressing pain complications and reassuring low addiction risk educates and encourages treatment. Dismissing concerns, normalizing endurance, or supporting refusal are non-therapeutic.
The nurse is caring for a client who has rubella. To prevent the spread of infection, which transmission-based precaution should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: B
Rationale: Rubella requires droplet precautions due to respiratory transmission.