After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?

Correct Answer: C

Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.

Correct Answer: D

Rationale: The assessment finding that suggests the client is experiencing an adverse effect of morphine (Duramorph) is a respiratory rate of 8 breaths/min. Morphine is a potent opioid analgesic that can cause respiratory depression as a side effect. When the respiratory rate decreases significantly, it indicates the potential for compromised breathing, which could progress to respiratory failure. This is a serious adverse effect that requires immediate attention and evaluation by healthcare providers. The client receiving continuous infusion of morphine should be closely monitored for signs of respiratory depression to prevent life-threatening consequences.

Correct Answer: C

Rationale: A transsphenoidal adenohypophysectomy is a surgical procedure performed to remove benign or malignant tumors located in the pituitary gland. Pituitary carcinoma refers to a type of cancer that originates in the pituitary gland. Therefore, this surgery is indicated for treating pituitary carcinoma by removing the tumor from the pituitary gland. After the surgery, hormone replacement therapy may be necessary to replace the hormones that were previously produced by the removed adenohypophysis (anterior pituitary gland).

Correct Answer: A

Rationale: The drug should be resumed when the WBC (white blood cell) count falls to 5,000/mm3. This is the appropriate indicator to monitor as a low WBC count may indicate the need for the medication to be restarted to support the immune system. It is important to closely monitor the WBC count as it is a crucial factor in gauging the body's ability to fight infections effectively. Resuming treatment at this point helps ensure that the client's immune system remains stable and can continue to function properly.

Correct Answer: D

Rationale: The nurse's signature on the surgical consent form indicates that the nurse has verified and confirmed that the patient has signed the consent form. This step is crucial to ensure that the patient has voluntarily given their consent for the surgical procedure. It does not mean that the nurse obtained or provided informed consent, answered all surgical procedure questions, or made decisions on behalf of the patient. The nurse's role is to act as a witness to the patient's signature on the consent form to acknowledge that the patient has agreed to the procedure and signed the document.