Nokea
When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?
- A. Immediately following chemotherapy.
- B. 30 minutes before the chemotherapy starts, then every 4 to 6 hours.
- C. When the 12-year-old requests medication for nausea, then every 4 hours as needed.
- D. On starting the chemotherapy infusion, and then routinely every 8 hours.
Correct Answer: B
Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.
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The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety?
- A. Reschedule the client's chemotherapy until the next week.
- B. Withhold giving the medication until the primary health care provider's partner makes rounds.
- C. Telephone the answering service and confer with the on-call primary health care provider.
- D. Confer with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly.
Correct Answer: C
Rationale: If the nurse believes a primary health care provider's prescription to be in error, the nurse must clarify the dosage with the client's primary health care provider or the primary health care provider's substitute before administering the medication. Rescheduling the client's chemotherapy is incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy. Withholding the medication until the partner makes rounds is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Checking with the pharmacist can assist the nurse in determining whether the dose prescribed is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed primary health care provider with prescriptive authority.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
- A. Monitor stools for blood.
- B. Clean oral cavity with soft swabs.
- C. Provide appropriate play activities.
- D. Check the rectal temperature every 4 hours.
- E. Administer acetaminophen suppositories for fever.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
- A. A prolapsed stoma
- B. A vitamin B12 deficiency
- C. Nocturnal enuresis
- D. GI stone formation
Correct Answer: A
Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.
A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?
- A. Apply petroleum jelly around the stoma daily.'
- B. Clean the area with alcohol wipes before applying the pouch.'
- C. Ensure the skin barrier fits snugly and clean with mild soap.'
- D. Change the pouch only once a week.'
Correct Answer: C
Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.