A 70-year-old patient with acute myelocytic leukemia is receiving sargramostim (Leukine). What is a priority nursing action for this patient?
A) Providing a quiet environment
B) Increasing fluids
C) Providing comfort measures related to nausea
D) Encouraging appropriate dietary intake
B
Feedback:
A common adverse effect of this drug is vomiting and diarrhea. Due to the patient's age it would be important to keep him hydrated. Vomiting and diarrhea can cause dehydration quickly in the elderly. Providing a quiet environment and comfort measures for the nausea would be important but not as critical as increasing fluids. Diet is very important to this patient; however, usually this drug causes a loss of appetite. Therefore, increasing fluids would be extremely important to the patient's nutritional status.
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Following a particularly violent incident which resulted in a client being placed in four-point restraints, the nurse recognizes feeling fearful of having to work with the client again. How should the nurse handle this emotion?
1. Recognize that feeling fear and getting into physical confrontations is "part of the job." 2. Accept the fear, process the event with other staff, and continue working with the client. 3. Ignore feelings of fear as it would impede the nurse's ability to manage the client effectively. 4. Engage in debriefing with the client to clear up hard feelings.
The nurse should instruct the client taking Coumadin to avoid which of the following herbal supplements?
a. aloe b. belladonna c. ginkgo d. licorice root
A client's response to assessment of the plantar reflex is to fan the toes and dorsiflect the big toe. The nurse should recognize that this response is indicative of:
a. a normal response c. corticospinal disease b. stereognosis d. a brain tumor