Nokea
A patient who is receiving chemotherapy for breast cancer develops thrombocytopenia. What should the nurse include in the care plan?
- A. Encourage light exercise.
- B. Avoid intramuscular injections.
- C. Do not administer aspirin.
- D. Use a soft toothbrush for oral care.
Correct Answer: B
Rationale: The correct answer is B: Avoid intramuscular injections. Thrombocytopenia is a condition characterized by low platelet count, which can lead to impaired blood clotting. Intramuscular injections can cause bleeding and bruising due to the decreased ability of blood to clot. Therefore, it is crucial to avoid invasive procedures like intramuscular injections to prevent excessive bleeding in patients with thrombocytopenia. Encouraging light exercise (choice A) can be beneficial for overall health but may not directly address the risk of bleeding. Avoiding aspirin (choice C) is important as it can further increase the risk of bleeding. Using a soft toothbrush for oral care (choice D) is a good practice, but it does not directly address the risk associated with intramuscular injections in patients with thrombocytopenia.
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What instruction should the nurse include in the discharge teaching for a patient with hypothyroidism prescribed levothyroxine?
- A. Take the medication with meals.
- B. Take the medication in the morning on an empty stomach.
- C. Discontinue the medication if you feel better.
- D. Double the dose if a dose is missed.
Correct Answer: B
Rationale: The correct answer is B: Take the medication in the morning on an empty stomach. Levothyroxine should be taken on an empty stomach, preferably 30 minutes to 1 hour before breakfast, to ensure optimal absorption. Food can interfere with absorption, so taking it with meals (choice A) is not recommended. Discontinuing the medication if feeling better (choice C) is dangerous as it can lead to a relapse of hypothyroidism. Doubling the dose if a dose is missed (choice D) can result in overdose and adverse effects. Therefore, choice B is the best option for optimal effectiveness of levothyroxine therapy.
A client with a new diagnosis of diabetes mellitus is learning to self-administer insulin. Which instruction should the nurse include?
- A. Store the insulin in the freezer.
- B. Administer the insulin at the same site each time.
- C. Rotate injection sites within the same region.
- D. Shake the vial vigorously before drawing up the insulin.
Correct Answer: C
Rationale: The correct answer is C: Rotate injection sites within the same region. This is important to prevent lipohypertrophy and ensure proper insulin absorption. Administering insulin at the same site each time (B) can lead to tissue damage. Storing insulin in the freezer (A) can alter its effectiveness. Shaking the vial vigorously (D) can cause air bubbles and affect insulin dosage accuracy. Rotation of injection sites within the same region is crucial for consistent absorption and preventing complications.
The sister of a patient diagnosed with BRCA gene¢â‚¬"related breast cancer asks the nurse, 'Do you think I should be tested for the gene?' Which response by the nurse is most appropriate?
- A. In most cases, breast cancer is not caused by the BRCA gene.
- B. It depends on how you will feel if the test is positive for the BRCA gene.
- C. There are many things to consider before deciding to have genetic testing.
- D. You should decide first whether you are willing to have a bilateral mastectomy.
Correct Answer: C
Rationale: The correct answer is C because genetic testing for the BRCA gene involves complex considerations beyond just the test results. By stating that there are many things to consider before deciding to have genetic testing, the nurse acknowledges the importance of discussing the potential implications of the test result, such as emotional, social, and medical factors. This response promotes informed decision-making and empowers the patient to make a well-considered choice.
Choices A, B, and D are incorrect:
A: This statement is inaccurate as a significant proportion of breast cancers are indeed linked to the BRCA gene mutations.
B: This response oversimplifies the decision-making process by focusing solely on emotional aspects, neglecting other critical factors that should be considered before genetic testing.
D: This option is not appropriate as it suggests a specific treatment option (bilateral mastectomy) without addressing the broader aspects of genetic testing and decision-making.
The patient admitted with diabetic ketoacidosis has rapid, deep respirations. What action should the nurse take?
- A. Administer the prescribed PRN lorazepam (Ativan).
- B. Start the prescribed PRN oxygen at 2 to 4 L/min.
- C. Administer the prescribed normal saline bolus and insulin.
- D. Encourage the patient to practice guided imagery for relaxation.
Correct Answer: C
Rationale: The correct answer is C, administer the prescribed normal saline bolus and insulin. In diabetic ketoacidosis, rapid, deep respirations, known as Kussmaul breathing, occur due to compensatory mechanisms to lower blood pH. Normal saline bolus helps correct dehydration and insulin therapy helps lower blood sugar levels, leading to improved acidosis. Option A is incorrect as lorazepam does not address the underlying cause of the rapid respirations. Option B is incorrect as oxygen is not the priority in this situation. Option D is incorrect as guided imagery does not address the physiological needs of the patient in this critical condition.
A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?
- A. Have the patient void immediately before the procedure.
- B. Position the patient flat in bed.
- C. Administer a full liquid diet.
- D. Encourage the patient to ambulate for 30 minutes.
Correct Answer: A
Rationale: The correct answer is A: Have the patient void immediately before the procedure. This step is crucial to prevent accidental puncture of the bladder during paracentesis. Voiding helps empty the bladder, reducing the risk of injury and ensuring a safer procedure.
Incorrect choices:
B: Position the patient flat in bed - Incorrect, as the patient should be in a sitting position with legs dangling over the side of the bed during the procedure.
C: Administer a full liquid diet - Incorrect, as a full liquid diet is not necessary for paracentesis preparation.
D: Encourage the patient to ambulate for 30 minutes - Incorrect, as ambulation is not relevant to preparing for paracentesis.