Nokea
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client’s urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: B
Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.
You may also like to solve these questions
A 90 y.o. nursing home resident with stage 2 Alzheimer’s disease is found alone and crying in the dining room. She says she lost her mother and doesn’t know what to do. Which response by the nurse will help calm the resident?
- A. “Remember your mother has been dead for 30 years. You forgot again, didn’t you?”
- B. “I’m sorry you lost your mother; let’s go and try to find her.”
- C. “Are you feeling frightened? I’m here and I will help you.”
- D. “You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do.”
Correct Answer: C
Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust.
Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
- A. Cough as the cuff is being deflated
- B. Take a deep breath as the nurse deflates the cuff
- C. Hold the breath as the cuff is being re-inflated
- D. Exhale deeply as the nurse re-inflates the cuff
Correct Answer: B
Rationale: The correct answer is B: Take a deep breath as the nurse deflates the cuff. This is the correct choice because asking the client to take a deep breath while the cuff is deflated helps prevent aspiration of secretions into the lower airway. When the cuff is deflated, the tracheostomy tube provides a direct pathway for secretions to travel upwards, and taking a deep breath facilitates the movement of secretions out of the trachea.
Choice A (Cough as the cuff is being deflated) is incorrect because coughing while the cuff is being deflated can increase the risk of aspiration as secretions may be forced into the lower airway.
Choice C (Hold the breath as the cuff is being re-inflated) is incorrect as holding the breath while the cuff is being re-inflated can hinder the clearance of secretions from the trachea.
Choice D (Exhale deeply as the nurse re-inflates the cuff) is incorrect
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
In the presence of coma or unconsciousness, the major therapeutic measure includes:
- A. Maintenance of a clear airway
- B. Good nursing care
- C. Retention of catheter
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.
The normal range of hemoglobin in the blood of an adult:
- A. 7-11 mg
- B. 14-20 mg
- C. 12-18 mg
- D. 20-26 mg
Correct Answer: C
Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.