A client is to receive Tetracaine prior to a Bronchoscopy. Which of the following actions should the nurse include in the plan of care?

Correct Answer: A

Rationale: The correct action the nurse should include in the plan of care is to keep the client NPO until the pharyngeal response returns. This is important to prevent aspiration until the client's normal pharyngeal sensation is restored, typically within about 1 hour after the procedure. Monitoring the insertion site for a hematoma, palpating the bladder, and maintaining the client on bed rest are not directly related to the administration of Tetracaine prior to a Bronchoscopy.

Correct Answer: D

Rationale: When a client is taking Somatropin to stimulate growth, monitoring urine for calcium is essential. Somatropin can lead to increased calcium levels in the urine, potentially increasing the risk of renal calculi formation. Therefore, assessing for calcium in the urine helps in early detection and prevention of this complication.

Correct Answer: D

Rationale: The correct answer is D) 32-year-old man who has essential hypertension. Administering the Varicella vaccine is contraindicated in pregnant women due to the theoretical risk of transmission to the fetus. Therefore, option A is incorrect. Option B is also incorrect because individuals with a severe allergy to neomycin should not receive the Varicella vaccine, as it contains this component. Option C is incorrect because the Varicella vaccine is not recommended for infants under 12 months of age. In this case, the 32-year-old man with essential hypertension is the most appropriate candidate for the Varicella vaccine. This population is at risk for complications from Varicella infection, and administering the vaccine can help protect him from contracting the disease. This scenario highlights the importance of considering individual health factors and contraindications when determining vaccine eligibility, ensuring the safety and efficacy of immunization practices.

Correct Answer: A

Rationale: In this scenario, the correct statement the nurse should include is option A) "You should use a soft-bristled toothbrush to prevent bleeding." This is the most appropriate advice because chemotherapy can cause thrombocytopenia, a condition characterized by a low platelet count, which increases the risk of bleeding. Using a soft-bristled toothbrush reduces the chance of gum injury and bleeding. Option B) "You should take aspirin for minor aches and pains" is incorrect because aspirin can further increase the risk of bleeding in a patient with thrombocytopenia due to its antiplatelet effects. Option C) "You should avoid contact with individuals who recently received live virus vaccines" is incorrect as it is not directly related to the adverse effects of chemotherapy in this context. Option D) "You should consume a diet low in protein to reduce the risk of renal damage" is incorrect because a low-protein diet is not typically recommended for cancer patients undergoing chemotherapy unless specifically indicated for a different medical reason. Educationally, it is crucial for nurses to provide accurate information to patients undergoing chemotherapy to minimize potential complications and improve their quality of life during treatment. Understanding the specific adverse effects of chemotherapy and how to manage them is essential for patient safety and well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Fever. Rituximab is a monoclonal antibody used to treat conditions like certain types of cancers and autoimmune diseases. One of the potential side effects of rituximab is infusion reactions, which can manifest as fever. By instructing the client to report fever, the nurse can monitor for any serious adverse reactions promptly. Option A) Dizziness is less likely to be directly related to rituximab and is a common side effect of many medications but not a specific concern with this drug. Option C) Urinary frequency is not typically associated with rituximab use and may not be a significant concern in this context. Option D) Dry mouth is also not a common or serious side effect of rituximab, so it is not the priority finding to report. Educationally, understanding the side effects and potential adverse reactions of medications is crucial for nurses to ensure the safety and well-being of their clients. Teaching clients to recognize and report specific symptoms can aid in early detection and management of any complications, thereby improving outcomes.