A client is receiving chemotherapy with paclitaxel for breast cancer. A priority nursing intervention is to
a. encourage the client to get adequate rest.
b. monitor the client's safety.
c. teach the client about the drug regimen.
d. watch for drug side effects.
B
All interventions are appropriate; however, paclitaxel can cause neurotoxicity, leading to gait instability and the risk of falls. Safety is the priority in this case.
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During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule
out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency
The nurse working at the bedside traditionally participates in which advocacy role? (Select all that apply.)
1. Legal 2. Self 3. Collective 4. Class 5. Citizen
During a previous home care patient visit, the nurse instructed the patient to obtain certain supplies for wound care and to create a specific area within the home for these supplies
The nurse sees during the current visit that the patient did neither of these actions. Which of the following should the nurse do? a. Assume the patient is unable to follow directions and phone the physician b. Ask the patient which part of the instructions they did not understand c. Tell the patient that home care is canceled because the patient is resistant to instruction d. Assess the patient for reasons why the in-structions were not carried out
During a maternal assessment, the nurse determines the fetus to be in a left occipitoanterior (LOA) position. Auscultation of the fetal heart rate should begin in the:
1. Right upper quadrant. 2. Left upper quadrant. 3. Right lower quadrant. 4. Left lower quadrant.