Nokea
A client reports skin dryness, redness, and scaling after radiation. What should the nurse advise?
- A. Apply hydrating lotions.
- B. Scrub the area vigorously.
- C. Cover the area with adhesive bandages.
- D. Avoid moisturizing the skin.
Correct Answer: A
Rationale: The correct answer is A: Apply hydrating lotions. After radiation, skin can become dry and irritated. Hydrating lotions help to moisturize the skin and reduce dryness, redness, and scaling. They provide a protective barrier and promote skin healing. Advising the client to apply hydrating lotions is essential in maintaining skin integrity post-radiation.
Choice B: Scrubbing the area vigorously can further damage the skin and exacerbate irritation.
Choice C: Covering the area with adhesive bandages can trap moisture and lead to skin maceration.
Choice D: Avoiding moisturizing the skin can worsen dryness and discomfort.
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A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. CD4-T-cell count 180 cells/mm3
- B. White blood cell count 10,000/mm3
- C. Hemoglobin 12.5 g/dL
- D. Platelet count 200,000/mm3
Correct Answer: A
Rationale: The correct answer is A: CD4-T-cell count 180 cells/mm3. In HIV, monitoring CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates immunosuppression, increasing the risk of opportunistic infections. Therefore, it is the nurse's priority to monitor and ensure the CD4 count remains above critical levels to prevent complications.
Other choices are incorrect because:
B: White blood cell count is important but not as specific to HIV management.
C: Hemoglobin level is important for assessing anemia but not a priority in HIV care.
D: Platelet count is important for clotting but not directly related to HIV progression.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
- A. Electrocardiogram
- B. Chest X-ray
- C. Echocardiogram
- D. MRI of the chest
Correct Answer: D
Rationale: The correct answer is D. MRI of the chest should be clarified because the magnetic field can interfere with the function of the pacemaker, potentially causing harm to the patient. An electrocardiogram, chest X-ray, and echocardiogram are safe imaging tests that do not interfere with the pacemaker. Therefore, D is the correct answer that should be clarified to ensure patient safety.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will eat food that is very hot.
- C. I will drink large amounts of fluids with meals.
- D. I will eat a large meal right before chemotherapy.
Correct Answer: A
Rationale: Correct Answer: A: "I will eat food that is served at room temperature."
Rationale: Eating foods at room temperature can help decrease nausea because hot foods may worsen nausea, while cold foods could cause stomach discomfort. Room temperature foods are generally easier on the stomach and may be better tolerated during chemotherapy and radiation. This choice demonstrates an understanding of how food temperature can impact nausea.
Summary of other choices:
B: Eating very hot food can actually worsen nausea.
C: Drinking large amounts of fluids with meals can dilute stomach acid and enzymes, potentially worsening nausea.
D: Eating a large meal right before chemotherapy can lead to increased nausea and discomfort.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Preoxygenate the client with 100% oxygen for up to 3 min.
- B. Perform suctioning for no longer than 30 seconds.
- C. Apply suction while inserting the catheter.
- D. Limit oxygen therapy to 50% prior to suctioning.
Correct Answer: A
Rationale: The correct answer is A: Preoxygenate the client with 100% oxygen for up to 3 min. This is essential to prevent hypoxemia during the suctioning procedure. Adequate preoxygenation helps to increase the oxygen reserves in the client's lungs, reducing the risk of oxygen desaturation during and after suctioning. This is particularly important for clients with COPD and an artificial airway, as they are already at risk for hypoxemia due to impaired lung function.
Choices B, C, and D are incorrect:
B: Performing suctioning for no longer than 30 seconds is a general guideline, but it is not specific to clients with COPD and an artificial airway.
C: Applying suction while inserting the catheter is incorrect as this can cause trauma to the airway and increase the risk of infection.
D: Limiting oxygen therapy to 50% prior to suctioning is incorrect as it can lead to hypoxemia in clients with
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Avoid reading for 1 week.
- C. Limit eye movements for 1 week.
- D. Do not bend forward at the waist for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This is important to prevent increased intraocular pressure that could lead to complications post cataract surgery. Lifting heavy objects can strain the eye and potentially disrupt the healing process.
B: Avoid reading for 1 week is incorrect as reading does not significantly impact intraocular pressure or the healing process post cataract surgery.
C: Limit eye movements for 1 week is incorrect as normal eye movements do not typically pose a risk to the surgical site after cataract extraction.
D: Do not bend forward at the waist for 1 week is incorrect as bending at the waist does not directly affect intraocular pressure or the healing of the eye after cataract surgery.