what safety measure should the nurse implement when administering chemotherapy
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Nursing Elites

HESI LPN

Adult Health Exam 1

1. What safety measure should be implemented when administering chemotherapy?

Correct answer: A

Rationale: When administering chemotherapy, it is crucial to use protective gloves and a gown to protect against exposure to hazardous drugs that can be harmful through skin contact. Choice B is incorrect because chemotherapy medication should be prepared in a designated area to prevent contamination and ensure accurate preparation. Choice C is incorrect as chemotherapy should be administered at the appropriate rate to ensure patient safety and avoid adverse effects. Choice D is incorrect as verifying client identifiers is important for medication administration in general but not a specific safety measure related to chemotherapy administration.

2. The client with hypertension is being taught about lifestyle modifications. What topic is most important?

Correct answer: B

Rationale: Reducing salt intake is crucial for managing hypertension. Excessive salt consumption can lead to fluid retention, increasing blood pressure. While stress management, regular physical activity, and weight loss are beneficial for overall health, reducing salt intake is the most important lifestyle modification for controlling hypertension. Stress management may help reduce overall stress levels but does not directly impact blood pressure as salt intake does. Regular physical activity and weight loss can also benefit blood pressure control, but the immediate impact of reducing salt intake is more significant.

3. A client with asthma is prescribed an albuterol inhaler. Which instruction should the nurse provide?

Correct answer: C

Rationale: The correct instruction for the nurse to provide is to shake the inhaler before each use. Shaking the inhaler ensures proper mixing of the medication before administration, which is crucial for its effectiveness. Choice A is incorrect because albuterol inhalers are often used as a preventive measure, not just during asthma attacks. Choice B is a good practice to prevent oral fungal infections associated with inhaled corticosteroids, not typically with albuterol. Choice D is important for proper inhaler technique, but the primary step before inhaling is shaking the inhaler to ensure the medication is well mixed.

4. A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?

Correct answer: A

Rationale: Correct! Monitoring INR is essential in clients on anticoagulant therapy to ensure the blood's clotting time is within the therapeutic range, preventing further embolic events or excessive bleeding. Monitoring blood glucose levels (Choice B), blood pressure (Choice C), and temperature (Choice D) is important for various other conditions but is not directly related to anticoagulant therapy for a client with a history of pulmonary embolism.

5. What is the most important aspect of colostomy care to teach the client?

Correct answer: D

Rationale: The most crucial aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is essential to detect early signs of complications such as ischemia or infection. Changing the colostomy bag daily is important but not as critical as assessing the stoma for complications. Irrigating the colostomy daily is not a standard recommendation and should be performed based on healthcare provider's instructions. While avoiding high-fiber foods may be beneficial for some individuals with a colostomy, it is not the most important aspect of care compared to monitoring the stoma for complications.

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