A nurse is caring for a client who received chemotherapy the day before. Which of the following items requires the nurse to implement special handling precautions?

Water pitcher on client's bedside table

Client's urine in the bedside commode

Client's bed linens after use

Food tray and utensils from client's breakfast

Answer and Explanation

The Correct Answer is B

A. Water pitcher on client's bedside table: Water does not require special handling after chemotherapy. The nurse should ensure that the client has access to clean drinking water, but there are no special precautions for handling it.
B. Client's urine in the bedside commode: Client's urine after chemotherapy requires special handling, as it may contain cytotoxic drugs or their metabolites for up to 48 hours. Proper precautions, such as wearing gloves and using appropriate disposal methods, are necessary to avoid exposure.
C. Client's bed linens after use: Bed linens do not require special handling unless contaminated with bodily fluids such as urine or vomit that could contain chemotherapy drugs. Gloves should be worn, but no additional precautions are required unless the linens are contaminated.
D. Food tray and utensils from client's breakfast: Food trays and utensils do not require special handling after chemotherapy unless they are contaminated with body fluids. Normal cleaning and sanitation practices are sufficient.

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Correct Answer is A

Explanation

A. Bilateral coarse, crackle breath sounds: These are common findings in pulmonary edema due to fluid accumulation in the lungs. Furosemide, a diuretic, helps reduce fluid overload, making it an appropriate medication to help improve these symptoms by promoting diuresis.

B. Vesicular breath sounds over the peripheral lung fields: Vesicular breath sounds are normal, and do not indicate the need for diuretics. The prescription for furosemide would be more appropriate if the client had signs of fluid overload, such as crackles.

C. Potassium 3.2 mEq/L (3.5 mEq/L to 5.0 mEq/L): This indicates hypokalemia. Since furosemide can cause potassium depletion, the nurse should verify the prescription and monitor the client’s potassium levels closely, as additional supplementation may be needed.

D. Blood pressure 100/70 mm Hg: This blood pressure is on the lower side of normal. While furosemide can lower blood pressure, this finding alone doesn't specifically indicate that the pulmonary edema is being effectively treated.

A. Raise the drainage bag above the level of the client's abdomen. B. Elevate the client to the high-Fowler's position. C. Measure the amount of the dialysate outflow. D. Monitor the access site for drainage. E. Reposition the client onto the other side.

Correct Answer is ["B","C","E"]

Explanation

A. Raise the drainage bag above the level of the client's abdomen: This would decrease the flow rate of the dialysate. To facilitate proper drainage, the drainage bag should be kept lower than the level of the client's abdomen to allow gravity to assist in the outflow of dialysate.

B. Elevate the client to the high-Fowler's position: Elevating the client to a high-Fowler's position (sitting up at a 90-degree angle) can help improve the flow of dialysate by using gravity to promote better drainage, especially if there is fluid retention in the abdomen.

C. Measure the amount of the dialysate outflow: It's important to measure the dialysate outflow to assess the effectiveness of the dialysis and ensure that the prescribed amount of fluid is being drained. A decrease in outflow could indicate a blockage, kinked catheter, or other complications.

D. Monitor the access site for drainage: While monitoring the access site is important for assessing infection or leakage, a decrease in the dialysate flow rate is not related to drainage from the access site. Therefore, this is not a priority for addressing the decrease in flow rate.

E. Reposition the client onto the other side: Repositioning the client can help resolve any issues with the catheter position, which may be causing the decrease in flow. Moving the client can help improve drainage if the catheter is obstructed or kinked.

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A nurse is caring for a client who received chemotherapy the day before. Which of the following items requires the nurse to implement special handling precautions?

Nursing Test Bank

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