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A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?
- A. Discard the radioactive device in the client's trash can.
- B. Limit time for visitors to 2 hr per day.
- C. Instruct visitors to remain 3 feet from the client.
- D. Keep soiled bed linens in the client's room.
Correct Answer: C
Rationale: The correct answer is C: Instruct visitors to remain 3 feet from the client. This is because brachytherapy involves the internal placement of radioactive sources close to the tumor. By instructing visitors to remain 3 feet away, the nurse helps minimize their exposure to radiation.
A: Discarding the radioactive device in the client's trash can is incorrect as it can pose a radiation hazard to others.
B: Limiting time for visitors to 2 hours per day does not directly address radiation exposure concerns.
D: Keeping soiled bed linens in the client's room does not address radiation safety for visitors.
In summary, option C is the best choice as it directly addresses radiation safety for visitors during brachytherapy treatment.
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A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?
- A. Blood glucose of 110 mg/dL
- B. Decrease in blood pressure
- C. Increase in urinary output
- D. Respiratory rate of 16/min
Correct Answer: B
Rationale: The correct answer is B: Decrease in blood pressure. Telmisartan is an angiotensin II receptor blocker used to treat hypertension. A decrease in blood pressure indicates that the medication is effective in controlling hypertension. This is the desired outcome of telmisartan therapy as it helps reduce the risk of cardiovascular events. Choices A, C, and D are not directly related to the effectiveness of telmisartan. Blood glucose level and urinary output are not typically influenced by telmisartan, and respiratory rate is not a primary indicator of its effectiveness. Therefore, the most appropriate indicator of telmisartan's effectiveness in this scenario is a decrease in blood pressure.
Medical History: Cerebrovascular accident (CVA) 2 years ago, Coronary artery disease, Hypertension, Hyperlipidemia. A nurse is reviewing the client's medical record. After reviewing the medical history, the nurse must determine which of the following actions to take.
For each potential provider’s prescription, the nurse must select if the action is Anticipated, Nonessential, or Contraindicated for the client.
- A. Encourage the client to cough
- B. Elevate the head of the bed
- C. Assist the client to the bathroom
- D. Decrease oxygen to 1.5 L/min via nasal cannula
- E. Keep the client’s head in a midline position
- F. Initiate seizure precautions
Correct Answer: B, A, C, A
Rationale: The correct answer is based on the rationale below:
1. Elevate the head of the bed (B): This action is Anticipated as it helps prevent aspiration and promotes optimal respiratory function.
2. Encourage the client to cough (A): Also Anticipated as coughing helps clear secretions and maintain airway patency.
3. Assist the client to the bathroom (C): This is Non-essential unless there are specific concerns about the client's mobility or urgency.
4. Decrease oxygen to 1.5 L/min via nasal cannula (A): Contraindicated as it may compromise oxygenation, especially without proper assessment and orders.
Other choices:
- Keeping the client's head in a midline position (E) is not provided in the question stem, so it cannot be evaluated.
- Initiating seizure precautions (F) is not relevant to the client's immediate care based on the information given
A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect?
- A. Hyperalbuminemia
- B. Proteinuria
- C. Decreased serum lipid levels
- D. Decreased coagulation
Correct Answer: B
Rationale: The correct answer is B: Proteinuria. In nephrotic syndrome, there is increased permeability of the glomerular filtration membrane, leading to the loss of protein in the urine, specifically albumin. Hyperalbuminemia (choice A) is incorrect as albumin is lost in the urine. Decreased serum lipid levels (choice C) are incorrect because nephrotic syndrome is associated with hyperlipidemia due to altered lipid metabolism. Decreased coagulation (choice D) is incorrect as nephrotic syndrome is actually associated with a hypercoagulable state due to loss of anticoagulant proteins in the urine.
A nurse is caring for a client who has a full chest, which of the following actions should the nurse take?
- A. Inpatient fluid reduction
- B. Provide humidified oxygen
- C. Admonitor antibiotic medication
- D. Administer acute/micoplasm (café)
Correct Answer: B
Rationale: The correct answer is B: Provide humidified oxygen. This is because the client with a full chest may be experiencing difficulty breathing, and humidified oxygen can help improve oxygenation and relieve respiratory distress. Inpatient fluid reduction (choice A) is not indicated without further assessment. Admonitor antibiotic medication (choice C) is not directly related to addressing the client's respiratory distress. Administering acute/micoplasm (café) (choice D) is not a recognized medical intervention. Providing humidified oxygen is the most appropriate initial action to address the client's respiratory symptoms.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.
- B. You should avoid intercourse to prevent injury to your vagina.
- C. Women your age experience thickening of the vaginal tissue.
- D. Your symptoms are likely due to decreasing estrogen levels.
Correct Answer: D
Rationale: The correct answer is D: Your symptoms are likely due to decreasing estrogen levels. As women age, estrogen levels decrease leading to vaginal dryness and itching. This is a common symptom of menopause. By acknowledging the client's symptoms are likely due to decreasing estrogen levels, the nurse shows understanding and can provide appropriate education and treatment options. Choice A is incorrect as symptoms may persist without intervention. Choice B is incorrect as it does not address the underlying cause. Choice C is incorrect as it is not a typical experience for women of that age.