A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider.

Assess the color and content of the urine specimen for urinalysis.

Note the consistency of respiratory secretions and obtain a specimen for culture.

Compare all prior vital signs and continue to monitor every hour.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can cause gastrointestinal disturbances, including nausea.

Choice B reason: Vomiting is also a common symptom of digoxin toxicity. The medication can irritate the stomach and lead to vomiting.

Choice D reason: Hyperglycemia is not typically associated with digoxin toxicity. This symptom is unrelated to the effects of elevated digoxin levels.

Choice E reason: Photophobia is not a common symptom of digoxin toxicity. Symptoms of digoxin toxicity are more likely to be gastrointestinal or cardiovascular in nature.

A. Prolonged bleeding B. Dry mucous membrane C. Peaked T-waves D. Polyuria

Correct Answer is C

Explanation

Choice A reason: Prolonged bleeding is not a direct indicator of hyperkalemia. It is more commonly associated with coagulation disorders or conditions affecting blood clotting.

Choice B reason: Dry mucous membranes are more indicative of dehydration rather than hyperkalemia. Dehydration can result from a variety of conditions but is not specific to high potassium levels.

Choice C reason: Peaked T-waves on an electrocardiogram (ECG) are a classic sign of hyperkalemia. Elevated potassium levels affect the cardiac conduction system, leading to characteristic changes in the ECG, such as tall, peaked T-waves, widened QRS complexes, and flattened P-waves.

Choice D reason: Polyuria (excessive urination) is not typically associated with hyperkalemia. It is more commonly seen in conditions like diabetes mellitus or diabetes insipidus.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who was prescribed digoxin. Which manifestations correlate with a digoxin level of 3.0 (Range: 0.8-2.0)? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

Correct Answer is C

Explanation

During an emergency code situation, a primary healthcare provider about to defibrillate a client diagnosed with ventricular fibrillation says in a loud voice, "CLEAR!" Which action should the nurse implement immediately?

The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to positions used to breathe more easily. The nurse teaches the client to assume which position?

The nurse in the medical ICU suspects that the client is experiencing a thyroid storm. Which clinical manifestations should the nurse anticipate?

The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian Crisis?

A female client undergoing chemotherapy for breast cancer is distressed about hair loss. The most effective intervention by the nurse would be to:

A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

A client with myxedema reports experiencing fatigue, cold intolerance, and swelling around the eyes and face. The nurse plans care, understanding that these clinical manifestations are caused by a lack of or diminished production of which hormones? (Select all that apply)