Nokea
A nurse is preparing a client for radiation after a mastectomy. What adverse effect should be expected?
- A. Alopecia
- B. Diarrhea
- C. Fatigue
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Fatigue. Radiation therapy often causes fatigue due to its impact on healthy cells surrounding the treatment area. This can result in decreased energy levels and overall tiredness. Alopecia (A) is more commonly associated with chemotherapy. Diarrhea (B) is a potential side effect of certain chemotherapy drugs or radiation to the abdominal area. Weight gain (D) is not a typical adverse effect of radiation therapy.
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A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Increased serum calcium level
- B. Decreased serum calcium level
- C. Increased white blood cell count
- D. Decreased platelet count
Correct Answer: B
Rationale: The correct answer is B: Decreased serum calcium level. In fat embolism syndrome (FES), fat globules enter the bloodstream, leading to blockages in small blood vessels. This can cause a decrease in serum calcium due to the formation of fat emboli in the pulmonary circulation, leading to hypoxia and subsequent release of inflammatory mediators that can affect calcium levels. The other choices are incorrect because in FES, there is no direct effect on serum calcium levels. Increased serum calcium levels (choice A) are not expected in FES. While increased white blood cell count (choice C) and decreased platelet count (choice D) can occur in response to inflammation or infection associated with FES, they are not specific laboratory findings for FES.
A nurse is planning a presentation about HIV for a church-based group. Which of the following information about HIV transmission should the nurse include?
- A. It is primarily transmitted through direct contact with infected body fluids.
- B. It is transmitted through casual contact.
- C. It is transmitted through airborne droplets.
- D. It is only transmitted through sexual contact.
Correct Answer: A
Rationale: The correct answer is A because HIV is primarily transmitted through direct contact with infected body fluids such as blood, semen, vaginal fluids, and breast milk. This includes activities like unprotected sexual intercourse, sharing needles, and mother-to-child transmission during childbirth or breastfeeding. Casual contact (choice B) is not a common mode of transmission, and HIV is not transmitted through airborne droplets (choice C). While sexual contact is a significant mode of transmission, HIV can also be transmitted through other means involving infected body fluids. Thus, option D is incorrect as it is too limiting.
A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?
- A. Hyperglycemia
- B. Tachycardia
- C. Hypertension
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D: Bradycardia. Atenolol is a beta-blocker that slows down the heart rate, leading to bradycardia as an adverse effect. This occurs because atenolol blocks the action of adrenaline on the heart, causing the heart to beat slower. Hyperglycemia (A) is not a common adverse effect of atenolol; in fact, it may even lower blood sugar levels slightly. Tachycardia (B) and hypertension (C) are the opposite effects of atenolol, as it is used to treat high blood pressure and reduce heart rate. Therefore, these would not be expected adverse effects.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Inspect the mouth for signs of inhalation injuries
- B. Administer pain medication
- C. Place the client on oxygen therapy
- D. Start an intravenous line
Correct Answer: A
Rationale: The correct answer is A: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening and must be assessed immediately in burn patients. Burns to the face and chest increase the risk of inhalation injuries due to the proximity to the airway. Administering pain medication, placing the client on oxygen therapy, and starting an IV line are important interventions but inspecting the mouth for signs of inhalation injuries takes precedence in this situation to ensure the client's airway is not compromised.
A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?
- A. Increase calcium intake
- B. Avoid foods high in potassium
- C. Drink 3 L of fluid every day
- D. Limit vitamin C intake
Correct Answer: C
Rationale: The correct answer is C: Drink 3 L of fluid every day. Adequate fluid intake helps to dilute urine, reducing the concentration of calcium and oxalate, which are the main components of kidney stones. This instruction can help prevent the formation of new stones. Increasing calcium intake (Choice A) may actually be beneficial as it can bind with oxalate in the intestines, reducing its absorption and subsequent excretion in the urine. Avoiding foods high in potassium (Choice B) is not directly related to preventing calcium oxalate stones. Limiting vitamin C intake (Choice D) is not necessary unless the client is taking excessive amounts of vitamin C supplements, which can increase oxalate levels.