Nokea
Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?
- A. Keep the head of the bed elevated until the treatment is completed.
- B. Instruct the client to drink plenty of fluids during the treatment.
- C. Monitor the client's intravenous site hourly during the treatment.
- D. Administer an antiemetic before starting the chemotherapy.
Correct Answer: C
Rationale: Hourly IV site monitoring allows early detection of extravasation, preventing tissue damage from vesicant chemotherapy.
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The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
- A. Encourage continued maintenance of the walking routine.
- B. Advise less weight-bearing to prevent joint destruction.
- C. Recommend walking indoors for improved stability and safety.
- D. Suggest a calcium supplement along with continued walking.
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.
The healthcare provider prescribes penicillin 200,000 units intramuscularly for a patient with pneumonia. The available vial is labeled 'Penicillin 500,000 units/mL'. How much penicillin should be administered to the patient?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: B
Rationale: Dividing the prescribed dose (200,000 units) by the concentration (500,000 units/mL) yields 0.4 mL, the correct volume to administer.
A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?
- A. Chronic insomnia.
- B. Puffy, bleeding gums.
- C. Double vision.
- D. Blood pressure 100/78 mm Hg.
Correct Answer: C
Rationale: Double vision, or diplopia, can indicate phenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen.
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?
- A. Morphine.
- B. Oxycodone.
- C. Hydromorphone.
- D. Fentanyl.
Correct Answer: A
Rationale: Morphine is typically prescribed for myocardial infarction symptoms to relieve pain and reduce cardiac workload.