Nokea
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the number of health care workers entering the room.
- B. Encourage the client to engage in social activities.
- C. Ensure the client receives a flu vaccine during chemotherapy.
- D. Provide daily fresh fruits and vegetables.
Correct Answer: A
Rationale: The correct answer is A: Limit the number of health care workers entering the room. This is important because immunosuppressed clients are at higher risk for infections. By limiting the number of health care workers entering the room, the nurse can reduce the client's exposure to potential pathogens. This helps to maintain a clean and controlled environment for the client, decreasing the risk of acquiring infections.
Choice B is incorrect because social activities may expose the client to a higher risk of infections from others. Choice C is incorrect because administering a flu vaccine during chemotherapy may not be effective due to the client's compromised immune system. Choice D is incorrect as providing fresh fruits and vegetables does not directly address the risk of infections from health care workers.
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A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'll take this medication once a day in the evening.
- B. I'll take this medication only when I have an asthma attack.
- C. I'll take this medication in the morning before exercise.
- D. I'll stop the medication if I feel better.
Correct Answer: A
Rationale: Correct Answer: A. "I'll take this medication once a day in the evening."
Rationale:
1. Montelukast is usually taken once daily in the evening to provide optimal control of asthma symptoms.
2. Taking it consistently at the same time every day helps maintain a steady level of the medication in the body.
3. This statement shows the client understands the prescribed dosing schedule and is likely to adhere to it.
Summary of other choices:
B. Incorrect: Waiting to take the medication only during an asthma attack is not the correct way to manage asthma as montelukast is meant for daily maintenance.
C. Incorrect: Taking the medication before exercise is not the recommended timing for montelukast administration.
D. Incorrect: Stopping the medication when feeling better can lead to a worsening of asthma symptoms as montelukast helps prevent asthma attacks.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
- A. A room with air exhaust directly to the outdoor environment
- B. A room with a ventilated ceiling fan
- C. A room with a window and curtains that close
- D. A shared room with other tuberculosis clients
Correct Answer: A
Rationale: The correct answer is A: A room with air exhaust directly to the outdoor environment. This is the appropriate room assignment for a client with active tuberculosis because it helps prevent the spread of airborne infectious particles. The air exhaust system ensures that contaminated air is not recirculated within the unit, reducing the risk of transmission to other patients and staff.
Choice B (A room with a ventilated ceiling fan) is incorrect because a ceiling fan does not provide sufficient ventilation to prevent the spread of tuberculosis.
Choice C (A room with a window and curtains that close) is also incorrect as it does not address the need for proper ventilation and containment of infectious particles.
Choice D (A shared room with other tuberculosis clients) is clearly incorrect as it would increase the risk of transmission among the clients.
In summary, the correct room assignment for a client with active tuberculosis should prioritize containment and ventilation to minimize the risk of spreading the infection to others.
A nurse is caring for a client who the provider suspects might have pernicious anemia. The nurse should expect the provider to prescribe which of the following diagnostic tests?
- A. Schilling test
- B. Complete blood count (CBC)
- C. Vitamin B12 level
- D. Bone marrow biopsy
Correct Answer: A
Rationale: The correct answer is A: Schilling test. Pernicious anemia is caused by vitamin B12 deficiency, often due to poor absorption. The Schilling test is specifically used to diagnose pernicious anemia by evaluating the body's ability to absorb vitamin B12. The test involves giving the patient a small amount of radioactive vitamin B12 to determine how well it is absorbed and utilized by the body. This test helps to differentiate pernicious anemia from other causes of B12 deficiency.
Choice B (Complete blood count) is a general test that may show abnormalities in red blood cells seen in anemia, but it does not specifically diagnose pernicious anemia. Choice C (Vitamin B12 level) alone may not differentiate between pernicious anemia and other causes of B12 deficiency. Choice D (Bone marrow biopsy) is not typically necessary for diagnosing pernicious anemia and is more invasive compared to the Schilling test.
A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching?
- A. I should avoid heavy lifting.
- B. Feces can be present in the vagina.
- C. I might experience urinary incontinence.
- D. Pelvic pressure may occur during intercourse.
Correct Answer: B
Rationale: The correct answer is B. Feces present in the vagina is not a manifestation of uterine prolapse; it is a symptom of rectocele. The other choices are correct for uterine prolapse: A - Heavy lifting can worsen prolapse, C - Urinary incontinence is common due to pelvic floor weakness, D - Pelvic pressure during intercourse is a symptom. Therefore, the client mentioning feces in the vagina indicates a need for further teaching on distinguishing between uterine prolapse and rectocele symptoms.