When prioritizing R.T.'s plan of care, which of these effects is the most serious?
What will be an ideal response?
The most serious toxicity is decreased bone marrow function causing immunosuppression, which
may lead to life-threatening infection, and thrombocytopenia, leading to hemorrhage.
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The school nurse is performing health screenings during the physical education class. The nurse plans to weigh, measure, and determine body mass index of the adolescents. The scale has been set up in the open gym to speed the process
What should the nurse do to maintain confidentiality of the findings? 1. Have a student worker record the screening findings on the appropriate adolescent's record. 2. Have a volunteer weigh and measure the adolescents and verbally give the findings to the nurse to calculate the body mass index and record. 3. Provide a privacy screen and have the health aid record the findings directly on the record. The nurse will then calculate body mass index. 4. Use a buddy system with the students, having the students measure each other and record the findings.
It is determined that a patient, who is in a hepatic coma, needs a laxative. Lactulose is prescribed. Which of the following should the nurse monitor to assess the efficacy of the lactulose therapy?
A) Water levels in the colon B) Oncotic pressure in the colon C) Blood ammonia levels D) Relief from symptoms
The nurse is assessing the cardiac status of a client with lung cancer. During the assessment the nurse notes that the client has muffled heart sounds and weak pulses during inspiration. What should the nurse do first?
1. Give the client a back rub. 2. Raise the head of the bed. 3. Notify the physician. 4. Assess urinary output.
A client who has had two previous cesarean births is in active labor when she suddenly complains of pain between her scapulae. Which should be the nurse's priority action?
a. Notify the health care provider promptly. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Reposition the client with her hips slightly elevated.