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A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Visitors from outside the hospital
- C. Foods high in vitamin C
- D. A humidifier in the room
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and potted plants can harbor bacteria and fungi, increasing the risk of infection. Restricting these items helps minimize exposure to pathogens. Choices B and D are incorrect as long as visitors are screened for infections and the humidifier is cleaned regularly. Choice C, foods high in vitamin C, is incorrect as these foods can actually help boost the immune system.
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A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Avoid reading for 1 week.
- C. Limit eye movements for 1 week.
- D. Do not bend forward at the waist for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This is important to prevent increased intraocular pressure that could lead to complications post cataract surgery. Lifting heavy objects can strain the eye and potentially disrupt the healing process.
B: Avoid reading for 1 week is incorrect as reading does not significantly impact intraocular pressure or the healing process post cataract surgery.
C: Limit eye movements for 1 week is incorrect as normal eye movements do not typically pose a risk to the surgical site after cataract extraction.
D: Do not bend forward at the waist for 1 week is incorrect as bending at the waist does not directly affect intraocular pressure or the healing of the eye after cataract surgery.
A nurse is planning care for a client with a T4 spinal cord injury at risk for UTIs. What should be included?
- A. Limit fluid intake.
- B. Encourage fluid intake at and between meals.
- C. Restrict intake of acidic foods.
- D. Use an indwelling catheter continuously.
Correct Answer: B
Rationale: The correct answer is B: Encourage fluid intake at and between meals. This is because increasing fluid intake helps to flush out bacteria from the urinary tract, reducing the risk of UTIs. Limiting fluid intake (choice A) can lead to concentrated urine, making it easier for bacteria to multiply. Restricting acidic foods (choice C) does not directly impact the risk of UTIs. Using an indwelling catheter continuously (choice D) actually increases the risk of UTIs due to the constant presence of a foreign body in the urinary tract. Encouraging fluid intake at and between meals is the most effective way to prevent UTIs in clients with spinal cord injuries.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma often spreads to lymph nodes.
- C. Basal cell carcinoma is most common in young adults.
- D. Basal cell carcinoma is curable with chemotherapy.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. This should be included in the educational program because basal cell carcinoma rarely metastasizes. Metastasis is the spread of cancer from the original site to other parts of the body, and in the case of basal cell carcinoma, it tends to remain localized. This information is crucial for patients to understand the prognosis and treatment options.
Explanation of why other choices are incorrect:
B: Basal cell carcinoma often spreads to lymph nodes - This statement is incorrect as basal cell carcinoma typically does not spread to lymph nodes.
C: Basal cell carcinoma is most common in young adults - Basal cell carcinoma is more common in older individuals, typically over the age of 50.
D: Basal cell carcinoma is curable with chemotherapy - While chemotherapy may be a treatment option for some cases of basal cell carcinoma, it is not the primary treatment and not always curative.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Abnormally prominent U wave
- B. Tachycardia
- C. Flattened P wave
- D. Prolonged PR interval
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.
A nurse cares for a client on ethambutol therapy for tuberculosis. What should be monitored?
- A. Hearing loss
- B. Visual acuity
- C. Liver function
- D. Blood glucose
Correct Answer: B
Rationale: The correct answer is B: Visual acuity. Ethambutol can cause optic neuritis, leading to visual disturbances. Monitoring visual acuity is crucial to detect any changes early.
Incorrect choices:
A: Hearing loss is associated with other medications for TB, not ethambutol.
C: Liver function is not typically affected by ethambutol.
D: Blood glucose is not directly impacted by ethambutol therapy.
In summary, monitoring visual acuity is essential due to the potential optic nerve toxicity of ethambutol, making it the most relevant parameter to monitor in this case.