Nokea
A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
- A. Position changes every 4 hours.
- B. Nasotracheal suctioning to clear secretions.
- C. Frequent linen changes.
- D. Frequent offering of a bedpan.
Correct Answer: C
Rationale: Diaphoresis from fever causes damp linens, which can lead to discomfort and skin breakdown; frequent linen changes are needed. Position changes aid lung expansion but are less urgent. Suctioning is invasive and not routinely required. Bedpan use depends on mobility, not fever.
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After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to:
- A. Monitor for signs and symptoms of hyperthyroidism.
- B. Rest for 1 week to prevent complications of the medication.
- C. Take thyroxine replacement for the remainder of the client's life.
- D. Assess for hypertension and tachycardia resulting from altered thyroid activity.
Correct Answer: C
Rationale: RAI often destroys enough thyroid tissue to cause hypothyroidism, requiring lifelong thyroxine replacement. Monitoring for hyperthyroidism is unnecessary post-treatment, and rest or assessing for hypertension/tachycardia are not primary concerns.
The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)?
- A. Valacyclovir
- B. Oseltamivir
- C. Azithromycin
- D. Omeprazole
Correct Answer: B
Rationale: Oseltamivir is an antiviral medication used to treat influenza. Choice A (valacyclovir) is for herpes, Choice C (azithromycin) is an antibiotic, and Choice D (omeprazole) is a proton pump inhibitor, none of which treat influenza.
A client with lymphoma reports severe abdominal pain and distension. The nurse suspects tumor lysis syndrome (TLS). Which laboratory result would confirm this diagnosis?
- A. Serum potassium of 6.2 mEq/L.
- B. Serum sodium of 140 mEq/L.
- C. Serum calcium of 9.0 mg/dL.
- D. Serum glucose of 110 mg/dL.
Correct Answer: A
Rationale: TLS causes rapid cell breakdown, releasing potassium, leading to hyperkalemia (potassium >5.5 mEq/L), which confirms the diagnosis and requires urgent management.
A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by:
- A. Normal relaxation of the chest.
- B. Gentle pressure of the rescuer's hand on the upper chest.
- C. The pressure of cardiac compressions.
- D. Turning the head to the side.
Correct Answer: A
Rationale: Exhalation during CPR occurs naturally due to chest relaxation after the rescuer delivers a breath, allowing air to exit the lungs.