Nokea
A client post-cystectomy is at risk for:
- A. Vitamin B12 deficiency.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Dehydration.
Correct Answer: A
Rationale: Cystectomy may impair vitamin B12 absorption due to ileum resection.
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The nurse has received a prescription for tenofovir and emtricitabine. The nurse understands that this medication is used to treat
- A. multiple sclerosis.
- B. human immunodeficiency virus (HIV).
- C. Parkinson's disease.
- D. Guillain-Barré syndrome.
Correct Answer: B
Rationale: Tenofovir and emtricitabine (Truvada) are antiretroviral medications used to treat and prevent HIV. They are not used for multiple sclerosis (A), Parkinson’s disease (C), or Guillain-Barré syndrome (D).
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the chart. Which action would be most appropriate for the nurse to implement?
- A. Wearing a protective gown and particulate respiratory mask when completing treatments.
- B. Washing hands before and after entering the room.
- C. Restricting visitors.
- D. Contacting the physician for an order for hematopoietic factors such as erythropoietin (Epogen, Procrit).
Correct Answer: B
Rationale: With a low white blood cell count (1,600/mm³) and absolute neutrophil count (<1,000/mm³), hand washing before and after entering the room is critical to prevent infection in this neutropenic client.
What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?
- A. Sit upright for 30 minutes after meals.
- B. Drink liquids with meals, avoiding caffeine.
- C. Avoid milk and other dairy products.
- D. Decrease the carbohydrate content of meals.
Correct Answer: D
Rationale: Decreasing carbohydrate content helps slow gastric emptying, reducing the risk of dumping syndrome. Sitting upright is helpful but less specific, and drinking liquids with meals can worsen symptoms.
The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has measured the correct dose when the syringe reads how many units?
Correct Answer: 32 units.
Rationale: The total dose is 10 units regular + 22 units NPH = 32 units, which should be drawn into one syringe for administration.