Nokea
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.
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The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
- A. Treatment of recurrent malignant effusion.
- B. Diagnosis of underlying disease.
- C. Palliation of symptoms.
- D. Relief of acute respiratory distress.
- E. Removal of the cancer cells.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (B), palliates symptoms like dyspnea (C), and relieves acute respiratory distress (D). It does not treat recurrent effusions or remove cancer cells.
A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:
- A. Irrigate the catheter with 30 mL of normal saline every 8 hours.
- B. Ensure that the catheter is draining freely.
- C. Clamp the catheter every 2 hours for 30 minutes.
- D. Ensure that the catheter drains at least 30 mL/hour.
Correct Answer: B
Rationale: Ensuring free drainage prevents obstruction or pressure buildup, which could harm the surgical site or kidney function.
A client post-lithotripsy asks about expected symptoms. The nurse should explain:
- A. Bruising at the site.
- B. Severe flank pain.
- C. Clear urine output.
- D. Fever above 102°F.
Correct Answer: A
Rationale: Bruising is common post-lithotripsy due to shock wave impact on tissues.
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
- A. Anemia.
- B. Osteoporosis.
- C. Weight loss.
- D. Local joint pain.
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.