a nurse is assessing a client who is receiving chemotherapy and has stomatitis which of the following findings should the nurse expect
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment B Quizlet

1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

2. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?

Correct answer: A

Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.

3. A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.

4. A client has a stool culture positive for C. difficile. What action should the nurse take?

Correct answer: D

Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.

5. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?

Correct answer: C

Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.

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