Nokea
Which of the following nursing interventions is essential when caring for a client who is receiving Cyclophosphamide (Cytoxin)?
- A. Monitoring vital signs q 1 hour
- B. Carefully monitoring of urine output
- C. Monitoring apical pulse
- D. Assessing for signs of increased intracranial pressure
Correct Answer: B
Rationale: Cyclophosphamide can cause hemorrhagic cystitis; monitoring urine output is critical to detect blood in the urine and ensure adequate hydration.
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A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.
The nurse is talking with a client who has type 1 diabetes mellitus and is receiving newly prescribed continuous subcutaneous insulin infusion therapy via an infusion pump. Which of the following statements by the client would indicate a correct understanding of the therapy?
- A. I will no longer need to test my blood glucose level throughout the day.
- B. I will no longer require an extra dose of insulin before my meals.
- C. My blood glucose levels should be more consistent throughout the day.
- D. The infusion set of my insulin pump should be changed daily.
Correct Answer: C
Rationale: Insulin pumps (C) provide steady insulin delivery, improving glucose stability. Glucose monitoring (A) and bolus doses (B) are still needed, and infusion sets are changed every 2-3 days, not daily (D).
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
Which nursing diagnosis is most appropriate for a client who has Cushing's syndrome?
- A. Risk for injury related to osteoporosis
- B. Pain related to cold intolerance
- C. Risk for deficient fluid volume related to excessive loss of sodium and water secondary to polyuria
- D. Risk for injury related to postural hypotension
Correct Answer: A
Rationale: Cushing's syndrome causes cortisol excess, leading to osteoporosis and increased fracture risk, making 'Risk for injury related to osteoporosis' the most appropriate diagnosis.
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown below. The nurse should recognize that the client is experiencing
- A. atrial flutter
- B. sinus bradycardia
- C. normal sinus rhythm
- D. premature atrial contractions
Correct Answer: C
Rationale: Without the ECG strip, normal sinus rhythm (C) is assumed for a stable client, characterized by regular P waves, QRS complexes, and a rate of 60-100 bpm. Other options indicate abnormal rhythms.