Nokea
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
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A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?
- A. Protamine
- B. Amicar
- C. Imferon
- D. Diltiazem
Correct Answer: A
Rationale: Protamine. Protamine binds heparin, making it ineffective.
After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest?
- A. 3 oz broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk
- B. 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
- C. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
- D. 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
Correct Answer: D
Rationale: 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. Canned fish and vegetables and cured meats are high in sodium. This meal does not contain any canned fish and/or vegetables or cured meats.
The nurse is caring for hospitalized clients. Which nursing actions require the nurse to use sterile gloves? Select all that apply.
- A. Insertion of a nasogastric tube
- B. Administration of an enema
- C. Administration of a subcutaneous injection
- D. Insertion of an indwelling urinary catheter
- E. Suctioning of a tracheostomy tube
Correct Answer: D,E
Rationale: D: Sterile gloves are required for urinary catheter insertion to prevent introducing pathogens. E: Sterile gloves are needed for tracheostomy suctioning to minimize infection risk. A, B, C involve non-sterile procedures.
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
- A. When I put my finger in the left hand the baby doesn't respond with a grasp.'
- B. My baby doesn't seem to follow when I shake toys in front of its face.'
- C. When it thundered loudly last night the baby didn't even jump.'
- D. When I put the baby in a back lying position that's how I find it hours later.'
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.
The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to
- A. maintain adequate hydration
- B. assist client to turn, deep breathe, and cough
- C. ambulate client within 12 hours
- D. splint incision
Correct Answer: B
Rationale: assist client to turn, deep breathe, and cough. Deep air excursion by turning, deep breathing, and coughing will expand the lungs and stimulate surfactant production. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in preventing atelectasis following surgery.