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A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own.
Incorrect Answers:
A: Purplish stools - This is not a common side effect of lymphangiography.
B: Redness of the upper part of the feet - Redness is not typically associated with this procedure.
D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.
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The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
- A. Decreased oral intake and decreased oxygen saturation when ambulating NursingStoreRN Decreased oxygen saturation when ambulating and reports of shortness of breath
- B. when getting out of bed
- C. Reports of shortness of breath when getting out of bed and a productive cough
- D. Productive cough and decreased oral intake
Correct Answer: B
Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity.
Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living.
Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance.
Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.
The nurse evaluates a certified nursing assistant. Which of the following actions by the CAN demonstrates understanding of standard precautions?
- A. Wears gloves during all client contact
- B. Cleans blood spills with soap and water
- C. Pours bulk blood and other secretions down a drain connected to a sanitary sewer
- D. Carries blood sample to the lab in an open basket
Correct Answer: A
Rationale: The correct answer is A because wearing gloves during all client contact is a key practice in standard precautions to prevent the spread of infection. Gloves act as a barrier to protect both the healthcare worker and the patient from potential pathogens. Choice B is incorrect as cleaning blood spills with soap and water is not sufficient for infection control. Choice C is incorrect because pouring bulk blood and secretions down a drain is a violation of biohazard disposal protocols. Choice D is incorrect as carrying a blood sample in an open basket can lead to potential exposure to bloodborne pathogens.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.
Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?
- A. To reduce the risk of seizures before and after surgery
- B. To avoid intraoperative complications
- C. To reduce cerebral edema
- D. To prevent postoperative vomiting
Correct Answer: A
Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures.
Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure.
Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure.
Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure.
Summary:
- Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin.
- Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario.
- Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.
Which nursing intervention is most appropriate for a client with multiple myeloma?
- A. Monitoring respiratory status
- B. Balancing rest and activity
- C. Restricting fluid intake
- D. Preventing bone injury
Correct Answer: D
Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.