Nokea
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
- A. Do not apply heat to the area of irradiation.
- B. Use sunscreen on the irradiated area.
- C. Apply lotion generously to the irradiated area.
- D. Rub the area with an alcohol-based lotion.
Correct Answer: A
Rationale: Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.
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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 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 is often fatal.
- C. Basal cell carcinoma metastasizes early.
- D. Basal cell carcinoma is more common in younger clients.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma rarely metastasizes to other parts of the body, making it highly curable through surgical excision. This information is crucial for patients to understand the low likelihood of the cancer spreading. Choices B and C are incorrect because basal cell carcinoma is not typically fatal nor does it metastasize early. Choice D is incorrect as basal cell carcinoma is more common in older adults, not younger clients.
A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?
- A. Serum sodium
- B. Serum glucose
- C. Troponin I
- D. White blood cell count
Correct Answer: C
Rationale: The correct answer is C: Troponin I. Troponin I is a specific marker for myocardial damage. After a myocardial infarction, the damaged heart muscle releases troponin I into the bloodstream, leading to elevated levels. This helps in diagnosing and monitoring the extent of myocardial damage.
A: Serum sodium levels are not typically affected by a myocardial infarction.
B: Serum glucose levels may be elevated due to stress response but are not specific to myocardial infarction.
D: White blood cell count may be elevated in response to inflammation caused by myocardial infarction, but it is not as specific as troponin I.
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. Flat T wave
- B. Prominent U wave
- C. ST elevation
- D. Wide QRS complex
Correct Answer: B
Rationale: The correct answer is B: Prominent U wave. Hypokalemia, or low potassium levels, can cause the U wave to become more prominent on an EKG strip. This is due to delayed repolarization of the ventricles. A flat T wave (choice A) is typically associated with ischemia or infarction. ST elevation (choice C) is often seen in conditions like myocardial infarction. A wide QRS complex (choice D) is indicative of conduction abnormalities. Choices E, F, and G are not relevant to the interpretation of hypokalemia on an EKG strip.
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.