a client is receiving rituximab what assessment by the nurse takes priority a client is receiving rituximab what assessment by the nurse takes priority
Logo

Nursing Elites

ATI RN

Oncology Test Bank

1. A client is receiving rituximab. What assessment by the nurse takes priority?

Correct answer: A

Rationale: When a client is receiving rituximab, the nurse's priority assessment should be monitoring the blood pressure. Rituximab can lead to infusion-related reactions, such as hypotension. Therefore, assessing the client's blood pressure is crucial to detect and manage any potential adverse reactions promptly. While monitoring temperature, oral mucous membranes, and pain are essential aspects of care, they are not the priority when a client is receiving rituximab.

2. Currently, the most widely used potent teratogen is __________.

Correct answer: D

Rationale: The correct answer is D, isotretinoin. Isotretinoin is a medication commonly used to treat severe acne, but it is a potent teratogen, meaning it can cause severe birth defects if taken during pregnancy. Aspirin (choice A) is not a widely used potent teratogen. Diethylstilbestrol (DES) (choice B) was a known teratogen, but it is not currently widely used. Thalidomide (choice C) was another historical teratogen, but it is also not currently widely used. Therefore, isotretinoin is the most relevant answer as it is a commonly used medication that poses a high risk of birth defects if used during pregnancy.

3. Following a child's return from exploratory surgery due to a gunshot wound to the abdomen, which nursing intervention should be excluded from the plan of care?

Correct answer: A

Rationale: Immediate initiation of oral feedings should be excluded from the plan of care post-abdominal surgery due to the risk of bowel complications like paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase these risks and hinder healing. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site is necessary to monitor for any signs of infection or complications. Administration of opioid narcotics for pain management is essential for ensuring the patient's comfort post-surgery. Visitation at the bedside provides emotional support and can aid in the patient's recovery. Therefore, the correct answer is to exclude immediate initiation of oral feedings.

4. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?

Correct answer: D

Rationale:

5. The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?

Correct answer: C

Rationale: Peripheral tissue perfusion is a major concern in the postoperative period following an abdominal aneurysm repair. Peripheral pulses should be checked frequently during the first 24 hours. A weak or absent pulse may be a sign of embolization or graft closure, especially if accompanied by a pale, cold, mottled extremity; the nurse should immediately report this to the surgeon. Risk for infection, deficient knowledge, and activity intolerance are all important nursing diagnoses in the postoperative period, but peripheral tissue perfusion is the most immediate concern.

Similar Questions

A nurse enters a client's room and finds the client pulseless. The client's living will requests no resuscitation be performed, but the provider has not written the prescription. Which of the following actions should the nurse take?
A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?
What physiologic state(s) produces the clinical manifestations of nervous system stimulation and excitement, such as overexcitability, nervousness, and tetany?
A client has a new prescription for Clopidogrel. Which of the following instructions should the nurse include?
A nurse recognizes which of the following as a primary goal of nursing?

Access More Features

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 30 days access @ $69.99

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 90 days access @ $149.99