After cancer chemotherapy, a client develops nausea and vomiting. For this client, the nurse should give the highest priority to which action in the plan of care
A. Serve small portions of bland food.
B. Encourage rhythmic breathing exercise.
C. Administer metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed.
D. Withhold fluids for the first 4 to 6 hours after chemotherapy administration.
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When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow
A. Frequent trips to the bathroom with an average output of 200 to 300 mL per void.
B. Intense urge to urinate with an average output of 250 mL.
C. A varying urge to urinate with an average output of 100 mL.
D. Uterus displaced to the right with increased vaginal bleeding.
When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris
A. "The pain lasted for about 45 minutes. "
B. "The pain resolved after I ate a sandwich. "
C. "The pain worsened when I took a deep breath. "
D. "The pain occurred while I was mowing the lawn. "
Otorrhea and rhinorrhea are most commonly seen with which type of skull fracture
A. Basilar.
B. Temporal.
C. Occipital.
D. Parietal.
A 9-month-old infant is admitted with diarrhea and deficient fluid volume. The nurse plans to assess this client's vital signs frequently. What other action would provide the most important assessment information
A. Measuring the infant's body weight.
B. Obtaining a stool specimen for analysis.
C. Obtaining a urine specimen for analysis.
D. Inspecting the infant's posterior fontanel.
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