On the fifth day of continuous infusion of cytarabine, the UAP reports C.O.'s vital signs to you
What additional assessments should you make at this time?
What will be an ideal response?
Because the most common sites of infection during chemotherapy are the lungs, blood, skin, urinary
tract, and GI tract, assess breath sounds and note the presence of a cough. If sputum is produced,
note the amount and color. Inspect the skin for any reddened, swollen, painful, or draining areas,
including the central line site. Ask her about any pain or burning on urination. Inspect the mouth
and pharynx, looking for any reddened, swollen, painful, or draining areas.
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When caring for a client, which assessment would the nurse use to correlate with a diagnosis of hypoparathyroidism?
a. Chvostek's sign c. tetany b. Homans' sign d. Trousseau's sign
A nursing manager is assessing a nursing home over concerns regarding institutional mistreatment of older patients. Which situation would warrant further concern over this issue?
1. A client refuses to take her morning shower. 2. A client screams at a patient care technician. 3. A client denies taking his morning medication. 4. A client curses out another nursing home patient.
The nurse applies supplemental oxygen to the client who has emphysema. Which oxygen delivery device does the nurse choose for the client?
1. Nasal cannula 2. Simple facemask 3. Nonrebreather mask 4. Partial rebreather mask
Anne goes into her pediatric patient's room for her 0400 assessment of a child who was admitted with dehydration 12 hours ago. Anne begins her assessment and knows that there is a medical emergency when the findings indicate:
1. A child with a regular heart rate and a respiratory rate at the high end of normal. 2. A child who is awake and wanting to play on the PS3. 3. A child who has a purple rash in his extremities, and it does not blanch. 4. A child who complains that he is tired and vomits thick mucus.