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 nurse is caring for the client with an IV. Which findings should prompt the nurse to conclude that the client is experiencing inflammation (phlebitis) at the IV insertion site? Select all that apply.
- A. Pain
- B. Redness
- C. Warmth
- D. Drainage
- E. Mottling
- F. Swelling
Correct Answer: A,B,C,F
Rationale: A: Pain indicates tissue irritation. B: Redness results from vasodilation. C: Warmth is caused by inflammation. F: Swelling occurs from fluid leakage. D: Drainage suggests infection. E: Mottling is unrelated.
Which information is most important for the nurse to reinforce with a male client who is about to undergo a vasectomy?
- A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.'
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.'
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you may return to work as soon as you feel up to it.'
- D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.'
Correct Answer: A
Rationale: All of these options are correct information. The most important point to reinforce is the continuing need to take additional action for birth control until the absence of sperm in the ejaculate is confirmed.
The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct Answer: C
Rationale: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral pulses should be checked immediately.
The nurse is caring for hospitalized clients. Which nursing actions require the nurse to use sterile gloves? Select all that apply.
- A. Insertion of a nasogastric tube
- B. Administration of an enema
- C. Administration of a subcutaneous injection
- D. Insertion of an indwelling urinary catheter
- E. Suctioning of a tracheostomy tube
Correct Answer: D,E
Rationale: D: Sterile gloves are required for urinary catheter insertion to prevent introducing pathogens. E: Sterile gloves are needed for tracheostomy suctioning to minimize infection risk. A, B, C involve non-sterile procedures.
The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct Answer: A
Rationale: Stop the infusion. This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion.