Nokea
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.
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A 56-year-old female who is receiving radiation therapy tells the nurse that she feels inadequate as a wife and mother because she can no longer carry out her usual duties with the same energy as before. What recommendations should the nurse make to help the client cope with this situation?
- A. Suggest that she reassign all household chores to other members of the family.
- B. Suggest that she prioritize her activities and ask for help from friends and family.
- C. Suggest that she ignore the household chores during the crisis period.
- D. Tell her not to worry so much because everyone gets a little tired at this phase of the therapy.
Correct Answer: B
Rationale: Prioritizing activities and seeking help from friends and family helps the client manage her energy and responsibilities, reducing feelings of inadequacy.
A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following stress interventions will be most helpful to the client?
- A. Review her current coping mechanisms and develop alternatives, if needed.
- B. Suggest a less stressful career in which she would still use her education and experience.
- C. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases.
- D. Prepare family members for the fact that she will have to work part-time.
Correct Answer: A
Rationale: Reviewing and developing coping mechanisms helps the client manage stress nbr without assuming drastic changes like altering her career or relying on others to adjust her workload. Preparing family for part-time work is premature and not directly stress-focused. CN: Psychosocial adaptation; CL: Synthesize
The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action?
- A. Document the prednisone with current medications.
- B. Notify the surgeon of the poison ivy.
- C. Notify the anesthesiologist of the prednisone administration.
- D. Send the client to surgery.
Correct Answer: C
Rationale: Prednisone use affects adrenal function and stress response, increasing risks during anesthesia. Notifying the anesthesiologist ensures proper perioperative management, such as stress-dose steroids.
When suctioning a tracheostomy or laryngectomy tube, the nurse should follow which of the following procedures?
- A. Use a sterile catheter each time the client is suctioned.
- B. Clean the catheter in sterile water after each use and reuse for no longer than 8 hours.
- C. Protect the catheter in sterile packaging between suctioning episodes.
- D. Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.
Correct Answer: A
Rationale: Using a sterile catheter each time minimizes infection risk in the airway. Reusing catheters, even if cleaned, increases infection risk.
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.