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1. A client receiving chemotherapy reports nausea and vomiting. What is the nurse's priority intervention?
- A. Administer antiemetic medication before meals
- B. Encourage the client to eat small, frequent meals
- C. Instruct the client to avoid eating during treatment
- D. Provide the client with cold beverages during meals
Correct answer: A
Rationale: The correct answer is A: Administer antiemetic medication before meals. When a client receiving chemotherapy reports nausea and vomiting, administering antiemetic medication before meals is a priority intervention to help reduce nausea associated with chemotherapy. This proactive approach can prevent or minimize the symptoms, improving the client's quality of life during treatment. Choice B is incorrect because while encouraging the client to eat small, frequent meals can be helpful, administering antiemetic medication is the priority to address the immediate symptoms. Choice C is incorrect as avoiding eating during treatment may lead to nutritional deficits, and choice D is incorrect because providing cold beverages during meals may not effectively address the nausea and vomiting symptoms.
2. A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return?
- A. Encourage deep breathing exercises
- B. Maintain the client in a supine position
- C. Apply a sequential compression device
- D. Massage the client's legs
Correct answer: C
Rationale: The correct answer is C: Apply a sequential compression device. Applying a sequential compression device promotes venous return by assisting with blood circulation in the lower extremities, reducing the risk of blood clots. Encouraging deep breathing exercises can help with lung expansion but does not directly promote venous return. Maintaining the client in a supine position may not be ideal for promoting venous return if the client is unable to move. Massaging the client's legs may be contraindicated postoperatively due to the risk of dislodging a clot or causing trauma to the surgical site.
3. How can a healthcare professional reduce the risk of falls in elderly patients?
- A. Encourage the use of assistive devices.
- B. Clear walkways.
- C. Ensure proper lighting.
- D. All of the above.
Correct answer: D
Rationale: All of these interventions are crucial in reducing the risk of falls in elderly patients. Encouraging the use of assistive devices helps provide support and stability, clearing walkways minimizes tripping hazards, and ensuring proper lighting enhances visibility and reduces the chances of falls. Therefore, choosing 'All of the above' is the most appropriate answer as each intervention plays a significant role in fall prevention.
4. What is an important consideration when administering a blood transfusion?
- A. Ensure the blood is compatible with the recipient's blood type
- B. Warm the blood to body temperature before administration
- C. Check the blood for clots before administration
- D. Ensure the recipient eats before the transfusion
Correct answer: A
Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.
5. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?
- A. Maintain two points of support on the ground at all times
- B. Use the cane on the weak side of the body
- C. Advance the cane 30 to 45 cm with each step
- D. Advance the cane and the strong leg simultaneously
Correct answer: A
Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.
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