A nurse is providing care for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
Wear gloves when handling the client's bed linens
Flush the client's urine down the toilet twice
Dispose of the client's intravenous tubing in a regular trash can
Wash the client's dishes with hot water and soap
The Correct Answer is B
Choice A reason: Wearing gloves when handling the client's bed linens is an incorrect action, as it is not enough to protect the nurse from exposure to the chemotherapy agents. The nurse should wear gloves, gown, and mask when handling any body fluids or items contaminated with body fluids from the client.
Choice B reason: Flushing the client's urine down the toilet twice is a correct action, as it helps to prevent contamination of the environment and other people with the chemotherapy agents. The nurse should also instruct the client and the family to do the same for 48 hours after the chemotherapy administration.
Choice C reason: Disposing of the client's intravenous tubing in a regular trash can is an incorrect action, as it poses a risk of exposure to the chemotherapy agents for the nurse and other staff. The nurse should dispose of the client's intravenous tubing in a biohazard container that is labeled as chemotherapy waste.
Choice D reason: Washing the client's dishes with hot water and soap is an incorrect action, as it is not sufficient to remove the chemotherapy agents from the dishes. The nurse should use disposable dishes and utensils for the client, or wash them separately with bleach and water.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.
Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.
Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.
Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.
Correct Answer is D
Explanation
Choice A reason: A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is at risk of tissue ischemia and necrosis, which are serious complications. However, this is not the highest priority, as the condition is chronic and not acute.
Choice B reason: A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is facing a life-threatening illness and needs emotional and physical support. However, this is not the highest priority, as the client is stable and not experiencing any immediate complications.
Choice C reason: A client who has MRSA and has an axillary temperature of 38°C (101°F) has an infection that can spread to other clients and staff, and needs isolation and antibiotic therapy. However, this is not the highest priority, as the fever is mild and the infection is treatable.
Choice D reason: A client who is postoperative following a laminectomy 12 hr ago and is unable to void has urinary retention, which can lead to bladder distension, pain, infection, and renal damage. This is the highest priority, as the client needs immediate intervention to relieve the obstruction and prevent further complications.
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