Nokea
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.
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The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.
- A. Digging in a sandbox
- B. Finger painting
- C. Playing a board game
- D. Playing soccer
- E. Pushing toy cars
Correct Answer: A,B,E
Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client?
- A. 2-point gait
- B. 3-point gait
- C. 4-point gait
- D. 5-point gait
Correct Answer: A
Rationale: The 2-point gait mimics normal walking, alternating crutch and opposite leg, suitable for full-weight bearing. 3-point is for non-weight bearing, 4-point is slower, and 5-point does not exist.
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.