A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

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Fundamentals of Nursing Nursing Process Questions Questions

Question 1 of 9

A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

Correct Answer: D

Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.

Question 2 of 9

Which method of data collection will the nurse use to establish a patient’s database?

Correct Answer: C

Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.

Question 3 of 9

Which food choice contains the highest kilocalorie?

Correct Answer: C

Rationale: The correct answer is C: Bacon. Bacon contains the highest kilocalorie among the given choices due to its high fat content. Fat provides 9 kilocalories per gram, while carbohydrates (like in bread and apple) provide 4 kilocalories per gram and protein (like in chicken) provides 4 kilocalories per gram. Bacon, being high in fat, has more kilocalories compared to the other choices. Summary: A: Apple - Low in fat, primarily consists of carbohydrates, hence lower in kilocalories. B: Chicken - Contains protein, lower in kilocalories compared to fat, hence not the highest kilocalorie choice. D: Bread - Mainly consists of carbohydrates, lower in kilocalories compared to fat, making it not the highest kilocalorie choice.

Question 4 of 9

A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?

Correct Answer: D

Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario. Incorrect choices: A: It will have no effect - Incorrect because infections and fever can impact insulin requirements. B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations. C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.

Question 5 of 9

Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Question 6 of 9

A nurse is preparing an IM injection of prednisolone acetate, 30 mg. It is supplied as 50 mg/mL. How many mL should the nurse prepare?

Correct Answer: B

Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.

Question 7 of 9

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. Diagnostic reasoning involves using assessment data and critical thinking skills to develop a nursing diagnosis. This process includes analyzing and interpreting data to make clinical judgments about the patient's health status. A: Assigning clinical cues is incorrect because this refers to identifying and documenting specific observations or findings during the assessment process, not the process of developing a nursing diagnosis. B: Defining characteristics is incorrect because this refers to the specific symptoms or manifestations used to support a nursing diagnosis, not the overall process of diagnostic reasoning. D: Diagnostic labeling is incorrect because this refers to assigning a formal name to the nursing diagnosis, not the process of critically analyzing assessment data to develop it.

Question 8 of 9

When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?

Correct Answer: D

Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.

Question 9 of 9

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?

Correct Answer: A

Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.

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