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: Soap or lotion can remove radiation site markings or irritate the skin, so they should be avoided to ensure accurate treatment.
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The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
- A. I will not let him use a straw.
- B. I will turn on the television during meals.
- C. Instead of whole pills, I will crush the pill and place it in custard.
- D. He will sit up for a half hour after eating.
Correct Answer: B
Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.
Which of the following statements by a client with a seizure disorder who is taking topiramate (Topamax) indicates that the client has understood the nurse's instruction?
- A. I will take the medicine before going to bed.
- B. I will drink 8 to 10 ten-ounce glasses of water a day.
- C. I will eat plenty of fresh fruits.
- D. I must take the medicine with a meal or snack.
Correct Answer: B
Rationale: Topiramate increases the risk of kidney stones, so adequate hydration (8-10 glasses of water daily) is essential to prevent this complication.
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
- A. Pneumonia
- B. Reaction to antiviral medication
- C. Tuberculosis
- D. Superinfection due to low CD4 count
Correct Answer: C
Rationale: The symptoms of low-grade fever, blood-tinged hemoptysis, fatigue, and night sweats are classic for tuberculosis.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.