A nurse is contributing to the development of an oral care protocol for clients who are receiving chemotherapy. Which of the following resources should the nurse utilize to identify interventions?

Standards of care published by the Oncology Nursing Society

Recommendations from a nurse who has worked in an outpatient chemotherapy clinic

A qualitative study exploring clients’ perspectives on receiving chemotherapy

A chapter on chemotherapy in a published textbook

Answer and Explanation

The Correct Answer is A

A.   Standards of care published by reputable organizations, such as the Oncology Nursing Society, provide evidence-based guidelines and best practices.
B.   While the experience of a nurse in a chemotherapy clinic is valuable, it may not represent standardized, evidence-based practices.
C.   A qualitative study may provide insights into clients' perspectives but may not necessarily offer specific interventions for oral care.
D.   Published textbooks can be valuable resources, but standards of care from professional organizations are generally more up-to-date and evidence-based.

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Correct Answer is C

Explanation

A. Vomiting is not a specific manifestation of sepsis.
B. Hypertension is not a typical finding in sepsis; hypotension is more common.
C. Altered mental status, such as confusion or lethargy, can be a sign of sepsis- induced organ dysfunction.
D. While an elevated white blood cell (WBC) count is often seen in infection, it alone does not indicate sepsis. The key in sepsis is the body's dysregulated response to infection leading to organ dysfunction.

A. A client who has a punctured femoral artery B. A client who has an open fracture C. A client who exhibits manifestations of multiple organ failure D. A client who has several closed fractures with bruising

Correct Answer is A

Explanation

A. Emergent (red tag) category includes patients with life-threatening injuries requiring immediate attention, such as a punctured femoral artery.
B. An open fracture may be urgent but not emergent unless associated with severe bleeding or other life-threatening complications.
C. Manifestations of multiple organ failure are severe but may fall into the expectant (black tag) category.
D. Closed fractures with bruising may be urgent but not emergent unless there are associated life-threatening complications.

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A nurse is contributing to the development of an oral care protocol for clients who are receiving chemotherapy. Which of the following resources should the nurse utilize to identify interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has an infection. Which of the following findings is a manifestation of sepsis?

Correct Answer is C

Explanation

A nurse is participating in a staff discussion about disaster triage. The nurse should include which of the following clients as an example emergent (red tag) category?

Correct Answer is A

Explanation

A nurse is caring for a client who has diabetes mellitus and had a below the knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?

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