Nokea
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, 'I refuse both radiation and chemotherapy because they are 'hot.' The next action for the nurse to take is to
- A. document the situation in the notes
- B. report the situation to the health care provider
- C. explain the client to the child's disease
- D. ask the client to talk about concerns regarding 'hot' treatments
Correct Answer: D
Rationale: ask the client to talk about concerns regarding 'hot' treatments. The 'hot-cold' system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
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The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.
An adult is receiving nasal oxygen at 6 L/min. The client asks the nurse why the oxygen is humidified. What should the nurse include when responding to the client?
- A. Humidifying oxygen helps to prevent fire.
- B. Humidity increases the concentration of oxygen.
- C. Humidity helps to keep the nasal passages from drying out.
- D. Humidity reduces the growth of organisms in the tubing.
Correct Answer: C
Rationale: Humidification prevents nasal mucosal drying and discomfort at higher oxygen flow rates like 6 L/min, not fire prevention, concentration increase, or bacterial reduction.
A client undergoes cryosurgery for the removal of a basal cell carcinoma on the ear. Which of the following best describes the appearance of the area a few days after surgery?
- A. It's dry, crusty, and itchy.
- B. It's oozing and painful.
- C. It's dry and tender.
- D. It's swollen, tender, and blistered.
Correct Answer: A
Rationale: Post-cryosurgery, the treated area typically forms a dry, crusty scab and may be itchy as it heals.
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).