Nokea
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct Answer: A
Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
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There are many types of torts that can be committed against clients. They include all of the following except:
- A. assault.
- B. battery.
- C. negligence.
- D. felony.
Correct Answer: D
Rationale: The correct answer is 'felony.' Felonies are serious crimes punishable by time in prison and are not considered types of torts. Types of torts include assault, battery, negligence, as well as other examples like slander, invasion of privacy, false imprisonment, and fraud. Assault involves the threat of harm, battery involves physical harm, and negligence involves a failure to exercise reasonable care. These are all civil wrongs (torts) rather than criminal offenses (felonies), making 'felony' the correct choice.
When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:
- A. that survivors have greater emotional turmoil and shock than when death is expected.
- B. that survivors have less emotional turmoil and shock than when death is expected.
- C. that survivors have the same emotional turmoil and shock as when death is expected.
- D. that survivors have little emotional turmoil and shock because they were not there.
Correct Answer: A
Rationale: The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock. Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock. Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock. Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.
Which of the following attitudes is essential in a nurse who assists clients during crises?
- A. viewing crisis intervention as the first step in solving bigger problems
- B. wanting to help clients solve all problems identified
- C. taking an active role in guiding the process
- D. feeling that work requires identification with all of a client's problems
Correct Answer: A
Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client's tongue
- D. Checks the client's ability to clench the teeth
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
- B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
- C. inform the client that it was not her fault, and support the client through the physical examination.
- D. question whether the woman had consensual sex and now just feels guilty.
Correct Answer: C
Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.