The nurse has received SBAR report on a patient with Cush and ecchymoses on the upper extremity.
What action should the nurse implement first?

Notify the healthcare provider.

Administer insulin using the sliding scale.

Provide skin care after assessing the skin.

Monitor intake and output and daily weight.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Notifying the healthcare provider is the appropriate first action when significant ecchymosis is observed in a patient with Cushing's syndrome, as it may indicate a need for medical intervention.

Choice B rationale

Administering insulin is not relevant as the primary concern here is the ecchymosis, not hyperglycemia.

Choice C rationale

While providing skin care is important, it does not address the potential underlying cause of the ecchymosis, necessitating provider notification first.

Choice D rationale

Monitoring intake and output and daily weight is a general care measure but does not address the immediate concern of ecchymosis observed.

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Correct Answer is C

Explanation

Choice A rationale

Wearing a dosimeter badge is essential for healthcare workers handling radioactive materials to monitor exposure, but it is not a standard practice for handling chemotherapy, which is typically not radioactive. Chemotherapy drugs are cytotoxic and require different safety measures, such as PPE.

Choice B rationale

While protecting patients during radiation therapy with a lead apron is necessary, it is not applicable for chemotherapy infusions. Chemotherapy involves the administration of cytotoxic drugs, not ionizing radiation, so protective measures focus on preventing exposure to these chemicals rather than shielding from radiation.

Choice C rationale

The nurse must wear personal protective equipment (PPE), including gloves and a gown, when handling chemotherapy to prevent exposure to these toxic drugs. PPE is crucial to protect healthcare workers from accidental spills, splashes, and skin contact with the chemotherapy agents, which can be harmful.

Choice D rationale

Disposal of chemotherapy waste should follow specific guidelines to prevent contamination and exposure. Sharps containers are for sharp objects like needles and blades, not for all chemotherapy waste. Chemotherapy waste should be disposed of in designated containers that comply with hazardous waste regulations to ensure safe handling and disposal.

A. The patient will have one formed bowel movement by the end of the shift. B. The patient's skin will be free of petechiae and purpura by discharge. C. The patient will tolerate meals without reports of nausea by the end of the day. D. The patient will be free from infection by discharge.

Correct Answer is D

Explanation

Choice A rationale

Filgrastim (G-CSF) is used to stimulate the production of white blood cells to decrease the risk of infection. A formed bowel movement is unrelated to the specific outcomes of this medication.

Choice B rationale

While filgrastim can improve overall blood cell counts, its primary goal is to enhance neutrophil counts, rather than addressing skin petechiae or purpura, which may be related to platelet levels.

Choice C rationale

Filgrastim does not target gastrointestinal symptoms such as nausea. Instead, it is aimed at restoring neutrophil levels to reduce infection risk.

Choice D rationale

Filgrastim is specifically designed to increase neutrophil counts, thus helping the patient to be free from infections by discharge, which is a SMART goal.

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The nurse has received SBAR report on a patient with Cush and ecchymoses on the upper extremity.What action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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The nurse has received SBAR report on a patient with Cush and ecchymoses on the upper extremity.
What action should the nurse implement first?