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: Providing the client with written information in their spoken language is the appropriate action for the nurse to take. This would ensure that the client understands the information and can refer to it later. It would also respect the client's culture and preferences.
Choice B reason: Speaking very slowly during the teaching session is not an appropriate action for the nurse to take. This would not improve the communication or comprehension of the client. It might also be perceived as patronizing or disrespectful by the client.
Choice C reason: Using medical terminology while explaining the medications is not an appropriate action for the nurse to take. This would confuse the client and hinder the learning process. The nurse should use simple and clear language that the client can understand.
Choice D reason: Having the client's family member who is present interpret is not an appropriate action for the nurse to take. This would compromise the accuracy and confidentiality of the information. It might also create a conflict of interest or a bias for the family member. The nurse should use a professional interpreter or a translation device if available.
Correct Answer is D
Explanation
Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.
Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.
Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.
Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.
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