Nokea
A client with a history of breast cancer is admitted with complaints of fatigue. The nurse should give priority to:
- A. Monitoring for anemia
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Fatigue in breast cancer may indicate anemia, so monitoring for anemia is the priority.
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Which of the following statements applies to the care of the client hospitalized with influenza?
- A. The nurse should wear an N-95 mask when caring for the client.
- B. The client may cohort with another client hospitalized with the same diagnosis.
- C. Equipment used in the client's care should remain in the room until the client is discharged.
- D. The door to the client's room may remain open to the hallway.
- E. The nurse should wear a mask when direct care of the client is required.
Correct Answer: B, C, E
Rationale: Influenza requires droplet precautions: cohorting with same diagnosis (B), keeping equipment in the room (C), and wearing a mask for direct care (E). N-95 masks (A) are for airborne diseases (e.g., TB). The door should remain closed (D) to limit droplet spread.
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
- A. Depression
- B. Agitation
- C. Psychotic ideation
- D. Anhedonia
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
The registered nurse is making assignments for the day. Which client should be assigned to the nurse who is pregnant?
- A. The client with HIV treated with Pentam (pentamidine)
- B. The client with cervical cancer treated with a radium implant
- C. The client with RSV treated with Virazole (ribavirin)
- D. The client with cytomegalovirus treated with Valcyte (valganciclovir)
Correct Answer: D
Rationale: Valganciclovir for cytomegalovirus poses minimal risk to a pregnant nurse as it is not teratogenic and standard precautions suffice. Pentamidine ribavirin and radium implants carry higher risks due to potential teratogenicity or radiation exposure.
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
- A. Mother is concerned about her recovery.
- B. Mother calls infant by name.
- C. Mother lightly touches infant.
- D. Mother is concerned about her weight gain.
Correct Answer: B
Rationale: In the taking-hold phase, the mother actively engages with the infant, such as calling the infant by name, indicating bonding.
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. NPH
- B. Human or pork
- C. Regular
- D. Long acting
Correct Answer: C
Rationale: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. Only regular insulin can be given IV.