Nokea
Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.
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The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
- A. Decreased cardiac output
- B. Tissue hypoxia
- C. Cerebral edema
- D. Reduced oxygen saturation
Correct Answer: B
Rationale: Tissue hypoxia. Iron deficiency anemia reduces oxygen-carrying capacity, causing tissue hypoxia.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
A client with schizophrenia is experiencing auditory hallucinations and is admitted for evaluation and treatment. A suitable activity for a client with schizophrenia who is experiencing auditory hallucinations is:
- A. Watching a movie with other clients
- B. Working on a large-piece puzzle
- C. Playing a game of solitaire
- D. Taking a walk with the nurse
Correct Answer: D
Rationale: Taking a walk with the nurse provides distraction and support, reducing focus on hallucinations. Group activities or solitary tasks (B, C) may be overwhelming or less therapeutic.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.