Answer to Question 1
ANS: A
Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the client's WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.
Answer to Question 2
ANS: D
A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.
A parish nurse checks the blood pressure of a church member
Establishing a caring and trusting relationship helps the client come to terms with a terminal illne
A nurse adjusts the rate of a client’s IV.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
The nurse conveys attentive listening through a posture of involvement
Testing patellar reflex, client in a sitting position