Nokea
A client is being treated with internal radiation (brachytherapy). The nurse explains to the client that
- A. visitors should wear gown, gloves, and mask when coming in the room.
- B. visitors are not allowed until the client is no longer receiving radiation therapy.
- C. visitors must stay at least 6 feet away from the client.
- D. visitors should not bring any cards or gifts into the room because they can become radioactive.
Correct Answer: C
Rationale: Brachytherapy requires distance precautions; visitors must stay 6 feet away to minimize radiation exposure. Gowns/masks are not needed, visitors are allowed, and gifts do not become radioactive.
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The nurse working in an outpatient clinic is preparing to teach insulin injection to an elderly male client who is hard of hearing yet refuses to wear prescribed hearing aids. Which of the following communication strategies would be most appropriate for the nurse to use?
- A. speak in a high-pitched voice
- B. use sign language
- C. ensure the room.Concurrent is well lit
- D. refrain from touching the client
Correct Answer: C
Rationale: A well-lit room enhances visual cues, aiding communication for a client with hearing difficulties who relies on lip-reading or facial expressions.
The nurse has just administered morphine 4 mg IV to a client with severe pain from a kidney stone. The client then asks to get up to the toilet. Which is the correct nursing action for this client?
- A. assist the client to the toilet
- B. offer the client a bedpan or urinal
- C. obtain an order for a Foley catheter
- D. place a bedside commode in the room
Correct Answer: B
Rationale: Morphine can cause sedation and dizziness, increasing fall risk. Offering a bedpan or urinal is safer than ambulating to the toilet.
The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
- A. N. gonorrhea
- B. H. influenza
- C. H. pylori
- D. E. coli
Correct Answer: C
Rationale: H. pylori is a primary causative factor in peptic ulcers, contributing to mucosal damage and ulcer formation.
A client who has been taking Coumadin (warfarin) was stabbed in the upper arm. His prothrombin time is over twice the normal amount. The nurse anticipates an order for
- A. fresh frozen plasma
- B. whole blood
- C. platelets
- D. packed red blood cells
Correct Answer: A
Rationale: Elevated prothrombin time indicates excessive anticoagulation. Fresh frozen plasma provides clotting factors to reverse warfarin’s effect and control bleeding.
The client with a pacemaker should be taught to:
- A. Report ankle edema
- B. Check his blood pressure daily
- C. Refrain from using a microwave oven
- D. Monitor his pulse rate
Correct Answer: D
Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.