A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first?

Correct Answer: C

Rationale: In this scenario, the correct nursing intervention to implement first is option C) Administer ondansetron hydrochloride (Zofran). Chemotherapy-induced nausea and vomiting (CINV) are common side effects that can significantly impact a pediatric patient's quality of life. Ondansetron is a well-established antiemetic medication that works by blocking serotonin receptors in the central nervous system, effectively reducing nausea and vomiting. Administering ondansetron as the first intervention is crucial to provide immediate relief to the client and prevent further complications such as dehydration and electrolyte imbalances. By addressing the vomiting promptly, the nurse can help the client feel more comfortable and improve their overall well-being during chemotherapy treatment. Now, let's analyze why the other options are incorrect: A) Teaching the client about the importance of hydration is essential, but addressing the vomiting should take precedence to prevent dehydration due to ongoing emesis. B) Reporting the volume of emesis to the healthcare provider is important but not the first action to take. Immediate management of the vomiting is necessary before informing the provider. D) Encouraging the client to limit movement may be helpful in reducing nausea, but administering an antiemetic medication should be the initial priority to address the vomiting effectively. In an educational context, understanding the priority interventions in managing chemotherapy-induced side effects is crucial for pediatric nurses. By prioritizing interventions based on the client's immediate needs, nurses can provide safe and effective care to pediatric patients undergoing chemotherapy and improve their treatment experience.

Correct Answer: D

Rationale: In this scenario, the best initial nursing action for a hospitalized client with chemotherapy-induced stomatitis complaining of mouth pain is to administer a topical analgesic per PRN protocol (Option D). This is the correct choice because a topical analgesic can provide direct relief to the specific area of pain in the mouth, offering immediate comfort to the client. Encouraging frequent mouth care (Option A) is important for overall oral health but may not address the immediate pain concern. Cleansing the tongue and mouth with glycerin swabs (Option B) can be soothing but may not provide adequate pain relief. Obtaining a soft diet for the client (Option C) is beneficial for comfort but does not directly address the pain concern as effectively as administering a topical analgesic. Educationally, it is essential for nursing students to understand the importance of prompt pain management in clients experiencing discomfort, especially in vulnerable populations like pediatric patients undergoing chemotherapy. By selecting the correct option, students learn the significance of assessing and addressing acute pain to improve the overall quality of care provided to patients.

Correct Answer: D

Rationale: The correct answer to this question is D) Complete head to toe neurological assessment. In this scenario, the patient's symptoms of confusion and projectile vomiting after a fall raise concerns about potential head injury or increased intracranial pressure. A head to toe neurological assessment is crucial in this situation to quickly identify any neurological deficits, assess for signs of increased intracranial pressure, and determine the extent of the injury. Option A) Determine client's last dose of corticosteroids is not the most appropriate initial intervention because in this case, the priority is to assess the patient's neurological status and ensure their safety. Option B) Determine neurological baseline prior to the fall is not the priority at this moment as the patient's current condition post-fall needs immediate attention. Option C) Administer a PRN IV antiemetic as prescribed is not the first intervention to implement because the patient's symptoms of confusion and vomiting are suggestive of a more urgent neurological issue that needs to be addressed first. In an educational context, it is essential for nurses to prioritize interventions based on the patient's presenting symptoms and potential life-threatening conditions. Understanding the importance of rapid assessment and recognizing signs of neurological compromise is critical in providing safe and effective care to patients, especially in emergent situations like this one.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Platelet count. A positive guaiac test of stool indicates the presence of occult (hidden) blood in the stool, which could be a sign of gastrointestinal bleeding. Platelet count is crucial in assessing for bleeding disorders or conditions that could lead to gastrointestinal bleeding. Platelets are essential for blood clotting, and a low platelet count could result in prolonged bleeding. Option A) Glucose is not directly related to the positive guaiac test result. Elevated glucose levels would be more indicative of diabetes. Option C) White blood cell count is not typically associated with a positive guaiac test result. White blood cells are more indicative of infection or inflammation. Option D) Amylase is an enzyme involved in the digestion of carbohydrates and is not directly related to occult blood in the stool. Educationally, understanding the rationale behind the need to review platelet count in this case reinforces the importance of interpreting laboratory results in a holistic manner. It also highlights the significance of recognizing the implications of abnormal findings, such as occult blood in the stool, and the need for further investigation to determine the underlying cause. This knowledge is crucial for nurses caring for pediatric patients to ensure timely and appropriate interventions for their well-being.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to include in the client's plan of care is to teach the client techniques for performing intermittent catheterization (Option A). This is the most appropriate intervention because it directly addresses the issue of urinary retention related to sensorimotor deficits in the client with multiple sclerosis. Teaching the client how to perform intermittent catheterization empowers them to effectively manage their urinary retention by ensuring timely and complete emptying of the bladder. This intervention also helps prevent complications such as urinary tract infections and bladder distention, which can further exacerbate the client's condition. Increasing the client's fluid intake to promote frequent urination (Option B) is not suitable in this case, as it does not address the underlying cause of urinary retention. In fact, increasing fluid intake without addressing the retention issue could lead to urinary overflow incontinence. Suggesting the use of incontinence pads for comfort (Option C) does not address the client's need for proper bladder emptying and may only serve as a temporary solution to managing the symptoms rather than the root cause. Administering anticholinergic medications to enhance bladder function (Option D) is not the first-line intervention for this client because these medications can have side effects and may not be necessary if the client can effectively manage their urinary retention through other means. In an educational context, understanding the rationale behind choosing the correct intervention is crucial for nurses caring for clients with neurological conditions affecting bladder function. Teaching clients self-care techniques empowers them to actively participate in their care, promoting independence and improving outcomes.