Nokea
A woman has just started receiving external radiation therapy. When the nurse enters the client's room, she notes that the client is scrubbing the area vigorously with soap and water. When asked about her actions, the woman replies that she is trying to get rid of the ugly purple marks. What is the best action for the nurse at this time?
- A. Explain that the purple marks must stay on her because they tell the doctors where to beam the radiation
- B. Suggest that alcohol will make it easier to remove the marks
- C. Say, 'You feel the marks are ugly.'
- D. Ask her if she checked with her physician before trying to remove the purple marks
Correct Answer: A
Rationale: Radiation marks guide precise targeting; explaining their necessity prevents removal and ensures effective treatment.
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An adult is to have a paracentesis performed today. What should the nurse do before the procedure?
- A. Encourage the client to drink large amounts of fluids
- B. Ask the client to empty her bladder just before the test
- C. Keep the client NPO until after the procedure
- D. Premedicate the client as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Fluid intake, NPO status, or premedication are not immediate pre-procedure priorities.
B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
- A. Family history of pressure ulcers
- B. Presence of existing pressure ulcers
- C. Potential areas of pressure ulcer development
- D. Overall risk of developing pressure ulcers
Correct Answer: D
Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
The nurse is caring for a 10-year-old child who has classic hemophilia. He is admitted with a swollen right knee that is very painful. The nurse should plan to include which of the following as a priority in the care of this child upon admission?
- A. Range-of-motion exercises to maintain joint mobility
- B. Ambulation at least three times a day to prevent immobility complications
- C. A bed cradle to reduce pain
- D. Offer 250 mL of fluid every hour to prevent hemarthrosis
Correct Answer: C
Rationale: A bed cradle keeps bedding off the painful, swollen knee (hemarthrosis), reducing discomfort, a priority in acute hemophilia management.
A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema.
On admission of this patient, which of the following should be assessed first?
- A. blood pressure
- B. skin breakdown
- C. serum potassium
- D. urine output
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.