Nokea
A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct Answer: B
Rationale: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function. Infection is the most frequent cause of morbidity and death in clients with cancer.
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The charge nurse is assigning staff to care for the client with disseminated herpes zoster. Which staff member should the charge nurse exclude from being assigned?
- A. A 7-month pregnant nurse who had confirmed chicken pox in childhood
- B. A 32-year-old nurse with unknown disease or vaccination history for chicken pox
- C. A 28-year-old nurse with a history of varicella vaccine and 2 small children at home
- D. A 60-year-old nurse with a history of live herpes zoster vaccine
Correct Answer: B
Rationale: B: Unknown immunity status poses a risk of varicella infection. A, C, D: These staff have immunity via prior infection or vaccination.
A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.'
- B. The tube will remove excess air from your chest.'
- C. The tube controls the amount of air that enters your chest.'
- D. The tube will seal the hole in your lung.'
Correct Answer: B
Rationale: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural space.
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. exercise doing weight bearing activities
- B. exercise to reduce weight
- C. avoid exercise activities that increase the risk of fracture
- D. exercise to strengthen muscles and thereby protect bones
Correct Answer: A
Rationale: exercise doing weight bearing activities. Weight bearing exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports the presence of this problem?
- A. When I put my finger in the left hand the baby doesn't respond with a grasp.'
- B. My baby doesn't seem to follow when I shake toys in front of its face.'
- C. When it thundered loudly last night the baby didn't even jump.'
- D. When I put the baby in a back lying position that's how I find it hours later.'
Correct Answer: D
Rationale: When I put the baby in a back lying position that's how I find it hours later.' Atonic cerebral palsy is characterized by low muscle tone and lack of movement, so the baby remaining in the same position for hours supports this diagnosis.
The nurse completed discharge teaching for the client with sutures in place after a skin biopsy. Which statements by the client indicate an understanding of the teaching? Select all that apply.
- A. "The incision should be clean, dry, and not separated."
- B. "I will return in 2 to 3 days to have the stitches removed."
- C. "If I have an elevated temperature, I'll contact my provider."
- D. "I'll keep the bandage on for a week before I check the incision."
- E. "Excessive redness, pain, or drainage may mean it is infected."
Correct Answer: A,C,E
Rationale: A: Clean, dry, intact incisions indicate proper care. C: Fever suggests infection, requiring follow-up. E: Redness, pain, or drainage are infection signs. B: Sutures are removed in 7-10 days. D: Incisions should be checked daily.