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A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)
- A. I will avoid crowds.
- B. I will wash my toothbrush weekly.
- C. I will take my temperature daily.
- D. I will eat plenty of fresh fruits and vegetables.
Correct Answer: A, C
Rationale: The correct answers are A and C. Neutropenia and chemotherapy increase the risk of infection. Avoiding crowds (A) reduces exposure to infectious agents. Taking temperature daily (C) helps detect early signs of infection. Washing toothbrush weekly (B) is important but daily is recommended. Eating fresh fruits and vegetables (D) is beneficial but may pose infection risk.
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A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is assessing a clients understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take?
- A. Proceed with obtaining the signature.
- B. Explain the procedure in detail.
- C. Contact the provider who will be performing the procedure.
- D. Have the client sign the form and address concerns later.
Correct Answer: C
Rationale: The correct answer is C: Contact the provider who will be performing the procedure. This is the best course of action because the provider is the most qualified individual to explain the procedure in detail and address any concerns the client may have. By involving the provider, the client can receive accurate and comprehensive information directly from the source. Proceeding with obtaining the signature (A) without ensuring the client's understanding can lead to potential legal and ethical issues. Explaining the procedure in detail (B) may not be sufficient if the client still has questions or concerns. Having the client sign the form and addressing concerns later (D) is not appropriate as it prioritizes paperwork over patient understanding and safety.
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade?
- A. Atrial fibrillation
- B. Jugular vein distention
- C. Bradycardia
- D. Hypotension
Correct Answer: B
Rationale: The correct answer is B: Jugular vein distention. In cardiac tamponade, fluid accumulates in the pericardial sac, compressing the heart. This leads to increased pressure in the heart chambers, causing jugular vein distention due to impaired venous return. A: Atrial fibrillation is a common arrhythmia but not specific to cardiac tamponade. C: Bradycardia is not a typical finding in cardiac tamponade as the body tries to compensate for decreased cardiac output. D: Hypotension can be present but is a late sign and not specific to cardiac tamponade.
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my medication with food to increase absorption.
- B. If my heart starts racing
- C. my provider might need to adjust my dosage.
- D. I will stop taking this medication once I feel better.
- E. I should take this medication at night before bed.
Correct Answer: B
Rationale: The correct answer is B because it indicates the client understands the potential side effect of levothyroxine, which is palpitations or a racing heart. This shows awareness of the need to monitor and report adverse effects to the healthcare provider promptly. Taking the medication with food (A) actually decreases its absorption. Dosage adjustments (C) are common in thyroid medication but don't necessarily demonstrate immediate understanding. Stopping the medication once feeling better (D) is incorrect as levothyroxine is usually a lifelong treatment. Taking medication at night (E) is not crucial for levothyroxine as long as it is taken consistently.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
- A. Ketones in the urine
- B. Weight gain
- C. Hypotension
- D. Decreased hunger
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (C) is not a typical manifestation. Decreased hunger (D) is more commonly seen in type 2 diabetes.