a patient reports nausea and vomiting after chemotherapy what is the nurses priority action
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.

2. A patient has a DNR (do-not-resuscitate) order but their family insists on resuscitation if necessary. What should the nurse do?

Correct answer: B

Rationale: The correct answer is B. The nurse must follow the legal DNR order, even if the family insists on resuscitation. Respecting the patient's wishes is crucial in providing ethical care. Choice A is incorrect because the nurse should prioritize the patient's documented wishes over the family's requests. Choice C may cause unnecessary delays in care as the DNR order is a legal document. Choice D is not the initial action to take in this situation; the nurse should first address the conflict between the family's wishes and the patient's DNR order.

3. A client with a urinary tract infection is prescribed ciprofloxacin. Which instruction should the nurse provide?

Correct answer: D

Rationale: The correct instruction for the nurse to provide to a client taking ciprofloxacin for a urinary tract infection is to avoid caffeine. Ciprofloxacin can interact with caffeine, potentially leading to increased side effects or reduced effectiveness. Choice A is incorrect because antibiotics should be taken for the full prescribed course, even if the client starts feeling better. Choice B is incorrect as ciprofloxacin should not be taken with dairy products or antacids as they can interfere with the absorption of the medication.

4. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

5. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?

Correct answer: B

Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.

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