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A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Obtain the client's vital signs.
- B. Perform a neurologic check.
- C. Turn the client on their side.
- D. Notify the rapid response team.
Correct Answer: C
Rationale: The correct action is to turn the client on their side (Choice C) during a tonic-clonic seizure to prevent aspiration and maintain a clear airway. This position helps saliva or vomit to drain out of the mouth, reducing the risk of choking. Obtaining vital signs (Choice A) and performing a neurologic check (Choice B) can wait until after the seizure is over. Notifying the rapid response team (Choice D) is not necessary for a single seizure unless complications arise.
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A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is caring for a client who has COPD. Which of the following findings require immediate follow-up?
- A. Client is oriented to person place and time.
- B. Client is restless.
- C. Pupils are reactive to light.
- D. Client is tachypneic cough is productive and mucous is yellow in color.
Correct Answer: D
Rationale: The correct answer is D because tachypnea, productive cough with yellow mucus in a client with COPD can indicate an exacerbation or infection, requiring immediate intervention. A: Orientation is not an urgent concern. B: Restlessness can be due to various reasons and doesn't necessarily indicate an emergency. C: Pupillary reactivity is not relevant to COPD management.
A nurse is caring for a client who is 3 hours postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?
- A. Encourage the client to perform circumduction of the foot.
- B. Keep the client's knees in a flexed position while they lie in bed.
- C. Massage the client's legs every 4 hours while they are awake.
- D. Limit the client's fluid intake to 2,000 mL daily.
Correct Answer: A
Rationale: Correct Answer: A. Encourage the client to perform circumduction of the foot.
Rationale:
1. Circumduction of the foot promotes blood flow in the lower extremity, preventing stasis and reducing the risk of venous thromboembolism.
2. This action helps in maintaining muscle tone and preventing blood clots in the postoperative period.
3. Encouraging mobility also prevents complications like deep vein thrombosis.
Summary of Incorrect Choices:
B. Keeping the client's knees in a flexed position may restrict blood flow and increase the risk of thromboembolism.
C. Massaging the client's legs can dislodge blood clots and lead to embolism.
D. Limiting fluid intake can increase the risk of dehydration and thickening of blood, which can contribute to thrombus formation.
A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy?
- A. Selenaline
- B. Ondansetron
- C. Diphenhydramine
- D. Methylprednisolone
Correct Answer: B
Rationale: The correct answer is B: Ondansetron. Ondansetron is a commonly used antiemetic medication that helps prevent chemotherapy-induced nausea and vomiting by blocking serotonin receptors in the gastrointestinal tract and chemoreceptor trigger zone. Administering ondansetron before chemotherapy can effectively reduce the incidence of these side effects. Selenaline (A) is not a recognized medication for managing chemotherapy-induced nausea and vomiting. Diphenhydramine (C) is an antihistamine that may be used for other types of nausea but is not the first-line treatment for chemotherapy-induced nausea. Methylprednisolone (D) is a corticosteroid that may be used to reduce inflammation but is not typically used as a primary antiemetic for chemotherapy-induced nausea and vomiting.