Nokea
A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.
- A. The client receiving chemotherapy who complains of a loss of appetite.
- B. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program.
- C. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence.
- D. The client with colon cancer who has questions about a high-fiber diet.
Correct Answer: C,A,B,D
Rationale: Urinary incontinence (C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (B), and then dietary questions (D).
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The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These traffic control measures are designed to:
- A. Protect the privacy of clients.
- B. Prevent electrical sparks that could ignite the anesthetic gases.
- C. Separate the family from the surgical team to prevent distraction of the client.
- D. Provide for an aseptic environment to prevent infection.
Correct Answer: D
Rationale: Restricting access to the operating room maintains an aseptic environment, reducing the risk of surgical site infections by limiting contamination.
The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
- A. Pour the solution over ice chips.
- B. Mix the solution with an antacid.
- C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
- D. Disguise the solution in a pureed fruit or vegetable.
Correct Answer: C
Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
- A. Decreased blood flow
- B. Increased blood flow
- C. Slow blood flow
- D. Thrombus formation
Correct Answer: A
Rationale: The hallmark of PVD is decreased blood flow due to arterial narrowing from atherosclerosis or other occlusive processes. This reduced flow causes ischemia, leading to claudication (pain during walking) that is relieved by rest. Increased or slow blood flow and thrombus formation are not the primary characteristics.
A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply.
- A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
- B. Choose good calcium sources, such as figs, broccoli, and almonds.
- C. Use alcohol in moderation because a moderate intake has no known negative effects.
- D. None of the above
Correct Answer: A,B
Rationale: Vitamin D and calcium are essential for bone health. Excessive alcohol can reduce bone density, so moderation alone is insufficient.
What areas of education should the nurse provide the narrowness to a factory making the cause respiratory irritation to reduce the risk of laryngeal cancer? Select all that apply.
- A. Smoking cessation concurrent with counseling.
- B. HEPA filter use in the home.
- C. Limiting alcohol use.
- D. Brushing teeth after every meal.
- E. Raising the voice to be heard over the noise in the factory.
Correct Answer: A,C
Rationale: Smoking and excessive alcohol use are major risk factors for laryngeal cancer; cessation and moderation reduce risk. HEPA filters address general air quality but not specific carcinogens. Brushing teeth and raising the voice are unrelated to laryngeal cancer risk.