Nokea
To combat the most common adverse effects of chemotherapy, the nurse would administer an:
- A. Antiemetic
- B. Antibiotic
- C. Antimetabolite
- D. Anticoagulant
Correct Answer: A
Rationale: The correct answer is A: Antiemetic. Chemotherapy commonly causes nausea and vomiting as adverse effects. Antiemetics are medications specifically designed to prevent or alleviate nausea and vomiting. Administering an antiemetic helps to manage these side effects and improve the patient's comfort and compliance with treatment. Antibiotics (choice B) are used to treat bacterial infections and are not directly related to combating chemotherapy side effects. Antimetabolites (choice C) are a type of chemotherapy drug, not used to combat its side effects. Anticoagulants (choice D) are used to prevent blood clots and are not indicated for managing chemotherapy-related nausea and vomiting.
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A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
- A. White, cottage cheese-like patches on the
- B. Red, open sores on the oral mucosa
- C. Rust-colored sputum
- D. Yellow tooth discoloration
Correct Answer: B
Rationale: The correct answer is B because red, open sores on the oral mucosa are a common sign of stomatitis, which can be caused by chemotherapy. Stomatitis is characterized by inflammation and ulceration of the mouth lining. The other choices are incorrect because:
A: White, cottage cheese-like patches are indicative of oral thrush, a fungal infection.
C: Rust-colored sputum may indicate a respiratory condition or infection, not stomatitis.
D: Yellow tooth discoloration is not typically associated with stomatitis, but can be caused by various factors such as poor oral hygiene or certain foods.
The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN
- A. Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process.
Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Mammography
- C. Fine needle aspiration
- D. Chest x-ray
Correct Answer: C
Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.
Which of the ff. is a normal hemoglobin value?
- A. 38% to 48%
- B. 48 to 54 mg%
- C. 12 to 18 g/100mL
- D. 27 to 36 g/dL
Correct Answer: C
Rationale: The correct answer is C: 12 to 18 g/100mL. Normal hemoglobin values typically range from 12 to 18 g/100mL in adults. This range reflects the normal concentration of hemoglobin in the blood and is commonly used as a reference range in clinical practice. Choices A, B, and D are incorrect because they do not fall within the typical normal range for hemoglobin levels. Choice A (38% to 48%) is a percentage range, not a direct measurement of hemoglobin concentration. Choice B (48 to 54 mg%) and Choice D (27 to 36 g/dL) are outside the normal range for hemoglobin levels in adults. Therefore, the most appropriate and accurate choice among the options provided is C (12 to 18 g/100mL) based on standard reference values for hemoglobin concentration in the blood.
Wilma knew that the maximum time when suctioning James is
- A. 10 seconds
- B. 20 seconds
- C. 30 seconds
- D. 45 seconds SITUATION: A 45 year old male construction worker was admitted to a tertiary hospital for incessant vomiting. Assessment disclosed: weak rapid pulse, acute weight loss of .5kg, furrows in his tongue, slow flattening of the skin was noted when the nurse released her pinch. Temperature: 35.8 C , BUN Creatinine ratio : 10 : 1, He also complains for postural hypotension. There was no infection.
Correct Answer: C
Rationale: The correct answer is C (30 seconds) because the maximum recommended time for suctioning a patient is typically around 10-15 seconds for each pass. Prolonged suctioning can lead to tissue damage, hypoxia, and increased risk of infection. In this case, given the patient's symptoms and medical history (vomiting, weight loss, dehydration, hypotension), it is crucial to limit suction time to prevent further complications. Choices A, B, and D are incorrect as they exceed the safe duration for suctioning and increase the risk of harm to the patient. Choice D, in particular, is significantly longer than the recommended time and could pose serious risks to the patient's health in this situation.