Nokea
A client receiving radiation to the head and neck is experiencing stomatitis. The nurse should recommend:
- A. Evaluation by a dentist.
- B. Alcohol-based mouth wash rinses.
- C. Artificial saliva.
- D. Vigorous brushing of teeth after each meal.
Correct Answer: C
Rationale: Artificial saliva helps relieve dry mouth and discomfort from stomatitis, a common side effect of head and neck radiation, by maintaining oral moisture.
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A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.
The nurse is assessing a client with cirrhosis who has developed hepatic encephalopathy. The nurse should notify the physician of a decrease in which lab serum that is a potential precipitating factor for hepatic encephalopathy?
- A. Aldosterone.
- B. Creatinine.
- C. Potassium.
- D. Protein.
Correct Answer: C
Rationale: Hypokalemia (C) increases ammonia production, precipitating hepatic encephalopathy. Aldosterone (A), creatinine (B), and protein (D) are not directly linked to this condition's onset.
A 60-year-old client with acute myeloid leukemia (AML) states that he overheard one of the other clients say that AML had a very poor prognosis. The client explains to the nurse that he had understood his doctor to say that he had a relatively good prognosis. Which is the nurse's best response?
- A. You must have misunderstood. Whom did you hear that from?'
- B. AML does have a very poor prognosis for poorly differentiated cells.'
- C. AML is the most common nonlymphocytic leukemia.'
- D. Your doctor stated your prognosis based on the differentiation of your cells.'
Correct Answer: D
Rationale: The prognosis for AML varies based on factors like cell differentiation, age, and genetics. The nurse should clarify that the doctor's prognosis was specific to the client's cell differentiation, reassuring him without dismissing his concerns. The other responses are either confrontational, overly general, or irrelevant.
The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?
- A. Acetazolamide
- B. Diphenhydramine
- C. Phenylephrine
- D. Nortriptyline
Correct Answer: A
Rationale: Acetazolamide is a carbonic anhydrase inhibitor used to reduce intraocular pressure in angle-closure glaucoma by decreasing aqueous humor production. Diphenhydramine, phenylephrine, and nortriptyline are not indicated for this condition.