Nokea
A client has been receiving radiation therapy for 3 weeks to treat his cancer. He is complaining of fatigue. Which of the following should be considered while the nurse plans interventions to help the client with the fatigue?
- A. Fatigue is a temporary problem that requires no active intervention
- B. The client should be closely examined to determine the cause of fatigue
- C. Fatigue indicates that the client's cancer is not under control
- D. The client should be encouraged to maintain activity to combat the fatigue
Correct Answer: B
Rationale: Fatigue during radiation therapy may have multiple causes (e.g., anemia, dehydration), requiring thorough assessment to guide interventions. It is not always temporary, not necessarily indicative of cancer progression, and activity should be balanced, not forced.
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The nurse is assessing a client with a suspected hip fracture. Which of the following findings is most likely to be present?
- A. External rotation of the affected leg.
- B. Increased range of motion in the hip.
- C. Absence of pain on weight-bearing.
- D. Symmetrical leg lengths.
Correct Answer: A
Rationale: External rotation of the affected leg is a common sign of a hip fracture due to muscle and bone displacement.
A client with a diagnosis of Tourette's syndrome is receiving haloperidol decanoate. The registered nurse asks the new nurse to describe the action of the medication. The new nurse responds correctly by stating that this medication has which action?
- A. Is a serotonin reuptake blocker
- B. Inhibits the breakdown of released acetylcholine
- C. Blocks the uptake of norepinephrine and serotonin
- D. Blocks the binding of dopamine to the postsynaptic dopamine receptors in the brain
Correct Answer: D
Rationale: Haloperidol decanoate is a typical antipsychotic medication used to manage symptoms of Tourette's syndrome, such as tics, by blocking the binding of dopamine to postsynaptic dopamine receptors in the brain, thereby reducing dopaminergic activity. It does not act as a serotonin reuptake blocker, inhibit acetylcholine breakdown, or block norepinephrine and serotonin uptake.
When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?
- A. It is not necessary to wash your hands as long as you use gloves.'
- B. Handwashing is the best method for preventing cross-contamination.'
- C. Waterless commercial products are not effective for killing organisms.'
- D. The hands do not serve as a source of infection.'
Correct Answer: B
Rationale: Handwashing is the most effective method to prevent cross-contamination, as hands are a primary source of infection transmission in healthcare settings.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
The nurse is caring for a client with a new tracheostomy. Which action is the priority during routine care?
- A. Suction the tracheostomy every 4 hours.
- B. Clean the stoma site with sterile saline.
- C. Change the tracheostomy ties daily.
- D. Monitor for signs of infection.
Correct Answer: B
Rationale: Cleaning the stoma site with sterile saline prevents infection and maintains skin integrity, making it the priority during routine tracheostomy care.