A client is taking G-CSF, or filgrastim (Neupogen). Which nursing interventions are indicated for the most common side effect of this medication?
a. Stool softeners and a high-fiber diet for constipation
b. High fluid intake and vitamin C for alkaline urine
c. Acetaminophen (Tylenol) and assessment for fever
d. Nonnarcotic analgesia and comfort measures for pain
ANS: D
Bone pain is the most common side effect of the granulocyte colony-stimulating factors.
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A method used to measure subjective experiences such as pain and fatigue is:
A) Q-sorts B) Vignettes C) Visual analog scales D) Likert scales
The nurse is caring for a pregnant 16-year-old who says, "I don't want my mother to know I'm pregnant. Please don't tell her." The nurse's best response would be:
A) "I'm sorry, but it would be unethical for me not to tell your mother you are pregnant." B) "I'm sorry, but I am legally obligated to talk with your mother." C) "I'm afraid you'll have to talk to your obstetrician, because she is the one to make that decision." D) "You have the right to confidentiality, and I cannot legally share the information that you are pregnant with anyone but you."
Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply
a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"
To perform oral pharyngeal suctioning, a nurse should first:
A. Apply gloves and mask B. Reassess respiratory status C. Remove the client's oxygen source D. Connect the tubing and suction catheter