Nokea
When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration? Select all that apply.
- A. Verify patency of the line by the presence of a blood return at regular intervals.
- B. Inspect the insertion site for swelling, erythema, or drainage.
- C. Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present.
- D. If unable to aspirate blood, reposition the client and encourage the client to cough.
- E. Contact the health care provider about verifying placement if the status is questionable.
Correct Answer: A,B,D,E
Rationale: Verifying patency (A), inspecting the site (B), repositioning for no blood return (D), and contacting the provider if placement is questionable (E) are critical to ensure safe chemotherapy administration. Administering without blood return (C) risks extravasation and tissue damage.
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The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with the client to clean the appliance routinely.
- A. Baking soda.
- B. Soap.
- C. Hydrogen peroxide.
- D. Alcohol.
Correct Answer: B
Rationale: Soap is safe and effective for cleaning reusable ileal conduit appliances, removing residue without damaging the appliance or irritating the skin.
A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy?
- A. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility.'
- B. Potency will be restored, but the client will remain infertile.'
- C. Fertility will be restored, but impotence and decreased libido will persist.'
- D. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.'
Correct Answer: D
Rationale: Hypophysectomy may disrupt pituitary hormone production, including those affecting sexual function. Exogenous hormones (e.g., testosterone) are often needed to restore erectile function.
A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy?
- A. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions.
- B. Contact the physician to determine if an alternative examination could be scheduled.
- C. Provide a dose of acetaminophen (Tylenol).
- D. Cancel the examination because of the hard X-ray table.
Correct Answer: A
Rationale: Dividing the session into shorter ones reduces discomfort, advocating for the client's comfort while ensuring the test is completed.
A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to:
- A. Prevent postoperative bladder infection.
- B. Reduce the number of intestinal bacteria.
- C. Decrease the potential for postoperative hypostatic pneumonia.
- D. Increase the body's immunologic response to the stressors of surgery.
Correct Answer: B
Rationale: Oral neomycin is administered preoperatively to reduce intestinal bacteria, decreasing the risk of infection during bowel surgery. It does not target bladder infections, pneumonia, or immune response directly. CN: Pharmacological and parenteral therapies; CL: Apply
A nurse is palpating a female client's breast while assessing for breast disease. In the illustration below, indicate the area of the breast in which tumors are most commonly found.
Correct Answer:
Rationale: Most breast tumors are found in the upper outer quadrant of the breast, as this area contains the most glandular tissue.