A nursing assistant assigned to care for a client with a radium implant tells the nurse, 'I don't want to be assigned to that radioactive patient.' The best action for the nurse to take is to:
- A. Tell the nursing assistant that the client's body acts as a shield.
- B. Point out that her behavior is uncaring.
- C. Instruct her regarding the use of a lead-lined apron.
- D. Ask the nursing assistant why she is afraid of the client.
Correct Answer: D
Rationale: Asking why the nursing assistant is afraid addresses her concerns and allows education. Claiming the body shields radiation is inaccurate. Calling her uncaring is unprofessional. Lead aprons are not typically used for implants.
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A 6-year-old was just diagnosed with pediculosis capitis. Which comment by the mother of the child indicates to the nurse in the physician's office that she does not understand how this condition is spread?
- A. I need to wash all his bed sheets in hot water.'
- B. I will call the school nurse and tell her.'
- C. I think he got this at our neighbor's house; it's very dirty.'
- D. I will tell my son not to wear other children's hats.'
Correct Answer: C
Rationale: Blaming a dirty house misrepresents lice transmission, which occurs via direct head-to-head contact or sharing items, indicating misunderstanding.
The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
A client diagnosed with pneumonia is experiencing shortness of breath, chest pain, and orthopnea. The chest x-ray reveals a very large right pleural effusion. Which intervention should the nurse anticipate for this client?
- A. Endotracheal intubation
- B. Paracentesis
- C. Thoracentesis
- D. Ventilation-perfusion scan
Correct Answer: C
Rationale: Thoracentesis removes fluid from the pleural space, relieving pressure on the lung and improving breathing in a large pleural effusion.
The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:
- A. Apply the eye ointment and eye drops together.
- B. Apply the eye drops, wait 5 minutes, and apply the ointment.
- C. Apply the eye ointment, wait 30 minutes, and apply the eye drops.
- D. Ask the pharmacist to supply the two medications in the same form.
Correct Answer: B
Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
- A. Avoid climbing stairs for 3 months
- B. Ambulate using crutches only
- C. Sleep in a supine position only
- D. Do not cross your legs
Correct Answer: D
Rationale: Do not cross your legs. Crossing legs can exceed the 90-degree hip flexion limit, risking dislocation.
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