Nokea
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol.
- B. Cover the radiation site with loose gauze dressing.
- C. Sprinkle baby powder over the radiated area.
- D. Refrain from using soap or lotion on the marked area.
Correct Answer: D
Rationale: Refraining from using soap or lotion preserves radiation site markings, ensuring accurate treatment. Removing markings, covering, or using powder risks disrupting the treatment field.
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Antibiotics are ordered for an adult who has a peptic ulcer. The client asks why antibiotics are prescribed. What should the nurse include when responding?
- A. Antibiotics are given to prevent secondary infections.
- B. Peptic ulcers are usually caused by bacteria.
- C. Antibiotics will create the environment necessary for the ulcers to heal.
- D. Antibiotics are given to prevent the infection from spreading to the bowel.
Correct Answer: B
Rationale: Peptic ulcers are often caused by Helicobacter pylori bacteria, and antibiotics eradicate the infection, promoting healing. They do not primarily prevent secondary infections, create healing environments, or stop bowel spread.
The nurse is working at a student health clinic at a large university. Which of the following signs and symptoms would cause the nurse to suspect cocaine abuse in a 20-year-old college student?
- A. Frequent sneezing, complaints of a sore throat, and a temperature of 100°F (37.8°C).
- B. Diarrhea, vomiting, and abdominal pain.
- C. Fatigue, dilated pupils, and anorexia.
- D. Complaints of insomnia, rhinorrhea, and facial pain.
Correct Answer: D
Rationale: Insomnia, rhinorrhea, and facial pain are associated with cocaine inhalation, the most common administration route. Options A, B, and C are less specific: A suggests infection, B indicates GI issues, and C could apply to other substances.
A client recently diagnosed with insulin-dependent diabetes mellitus (IDDM). As part of the treatment plan, the client receives Humulin N 32 units and Humulin R 8 units each morning.
Which of the following actions, if performed by the client while preparing the morning insulin injection, would require an intervention by the nurse?
- A. After the client draws up 8 units of Humulin R, she adds Humulin N to the syringe for a total of 40 units.
- B. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units.
- C. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
- D. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clear insulin always drawn up first (2) correct-Humulin R is clear and drawn up first, only 8 units are ordered, Humulin N is cloudy (3) allows you to withdraw medication later (4) allows you to withdraw medication later
A woman has been recently diagnosed with systemic lupus and shares with the nurse, 'I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy since I have lupus.'
- A. What is the best response by the nurse to a woman with systemic lupus considering pregnancy?
- B. Most women find that they feel better when they are pregnant.'
- C. How long have you been in remission?'
- D. Women with lupus frequently have slightly longer gestations.'
- E. It is best to become pregnant within the first six months of diagnosis.'
Correct Answer: B
Rationale: The nurse should assess the duration of remission, as women with systemic lupus erythematosus (SLE) should be in remission for at least 5 months before conceiving to minimize risks of maternal and fetal complications. Pregnancy does not typically improve SLE symptoms, gestation length is unaffected, and early pregnancy post-diagnosis is not recommended.
The nurse is caring for a client who is receiving IV ceftriaxone for a urinary tract infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are normal or less urgent.