The nurse on an oncology unit prepares to administer the fourth cycle of docetaxel (Taxotere) to a patient with breast cancer. Which clinical finding would cause the nurse to withhold the dose and call the prescriber?
a. Neutrophil count of 2000/mm3
b. Neutrophil count of 1700/mm3
c. Neutrophil count below 1500/mm3
d. Creatinine clearance of 130 mL/min/1.73 m2
ANS: C
If the neutrophil count drops below 1500/mm3, the nurse should withhold the dose and notify the prescriber. The other values do not indicate a need to withhold the dose.
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Due to frequent bouts of constipation, the nurse examines the bedfast nursing home resident for ulceration of the anus, called __________________
ANS:
The nurse is documenting care in the medical record. The nurse provides narrative documentation only for abnormal assessment findings. Which type of charting is the nurse using based on this example?
A) Computerized documentation B) Charting by exception (CBE) C) SOAP charting D) Focus charting
The temperature of your client 24 hours after a pleurodesis procedure is 100o F. What is your best action?
A. Obtain a specimen of chest fluid drainage for culture. B. Document the findings as the only action. C. Sponge bathe the client with tepid water. D. Notify the physician.
The new community health nurse introduces herself to the local minister and attends various neighborhood meetings. The nurse learns about the ethics, values, and culture of the neighborhood
The community is vocal about the need for public safety and the care of the homeless, especially in the winter. Which is the best rationale for considering all of the influences in the neighborhood affecting their health and well-being? A) The information can be used to obtain funds to create shelters for the homeless B) A neighborhood watch may be created with police support C) The information will help to effectively assess the community D) It will help the nurse create a controlled clinical environment