Nokea
A 52-year-old woman who has thyroid cancer is treated with radioactive iodine (Iodotope). What should be included in the nursing care plan following administration of the drug? Select all that apply.
- A. Tell the client not to eat or drink anything for four hours.
- B. Tell the client not to sleep in the same room with anyone for seven days following administration.
- C. Save the client's urine in a lead container for 48 hours.
- D. Limit contact with the client to 30 minutes per person per shift on day 1.
- E. Assign client to a single room.
- F. Tell client to report weight gain and severe fatigue to health care provider.
Correct Answer: B,D,E,F
Rationale: Radioactive iodine requires isolation in a single room, limited contact (30 minutes/shift), separate sleeping for 7 days, and reporting symptoms like fatigue or weight gain (hypothyroidism). NPO or urine storage are not standard.
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A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
A 9-month old is seen in the well child clinic. During the nursing assessment, the mother asks, 'Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying dada.' The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age:
- A. 1 month
- B. 2 months
- C. 4 months
- D. 8 months
Correct Answer: D
Rationale: Infants typically make cooing or babbling sounds by 6-8 months. Lack of sounds at 9 months warrants evaluation.
The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply.
- A. A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator
- B. Depth of chest compressions for infants should be half the depth of the anterior-posterior chest diameter
- C. Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants
- D. The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants
- E. You should assess the infant’s brachial pulse for no longer than 10 seconds
Correct Answer: A,E
Rationale: Two minutes of CPR before defibrillator retrieval and assessing the brachial pulse for ≤10 seconds align with infant CPR guidelines. Compression depth is about one-third the chest, two fingers are used, and the ratio is 30:2 for a single rescuer.
A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
The nurse is caring for a client who was admitted for treatment of schizoaffective disorder with visual hallucinations. He tells the nurse that he sees extraterrestrials that are coming to get him. What is the best nursing response?
- A. You know that extraterrestrials are make-believe.'
- B. Call his physician and report this visual hallucination.
- C. Ignore his comment and change the subject.
- D. You think someone is coming after you?'
Correct Answer: D
Rationale: Reflecting the client's statement validates his experience without reinforcing the hallucination, promoting therapeutic communication.