Nokea
During the induction stage for treatment of leukemia, the nurse should remove which items that the family has brought into the room?
- A. A Bible.
- B. A picture.
- C. A sachet of lavender.
- D. A hairbrush.
Correct Answer: C
Rationale: During leukemia induction therapy, the client is immunocompromised, and scented items like a lavender sachet may harbor bacteria or cause allergic reactions. A Bible, picture, and hairbrush (if clean) are safe and support emotional well-being.
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The development of a culturally sensitive health education program for the socioeconomically disadvantaged requires the nurse to:
- A. Locate the program at an existing government facility.
- B. Integrate folk beliefs and traditions into the content.
- C. Prepare materials in the primary language of the program sponsor.
- D. Exclude community leaders from initial planning efforts.
Correct Answer: B
Rationale: Integrating folk beliefs and traditions ensures the program is culturally relevant and increases acceptance and effectiveness among socioeconomically disadvantaged populations.
A client's husband expresses concern that his dying wife keeps saying, 'I have to go to the store.' Which of the following statements by the nurse will be most effective in assisting the husband to understand the dying process?
- A. Many dying clients are restless and can be treated with sedatives.
- B. The client may be fighting death and you should leave her alone.
- C. Comments related to going somewhere or leaving on a trip are common in dying clients.
- D. Decreased circulation and lack of oxygen to the brain often causes delirium.
Correct Answer: C
Rationale: Statements about leaving or going somewhere are common in dying clients, reflecting their subconscious preparation for death, and this explanation helps the husband understand the behavior.
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
- A. Quality of breath sounds.
- B. Presence of bowel sounds.
- C. Occurence of chest pain.
- D. Amount of peripheral edema.
- E. Color of nail beds.
Correct Answer: A,C,E
Rationale: Breath sounds (A) indicate lung involvement. Chest pain (C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
- A. Reassure the client that the nasoenteric tube is functioning.
- B. Assess the client for a rigid abdomen.
- C. Administer an opioid as ordered.
- D. Reposition the client on the left side.
Correct Answer: B
Rationale: Persistent acute pain despite a patent nasoenteric tube suggests a complication like peritonitis, indicated by a rigid abdomen, which requires immediate assessment. Reassurance, opioids, or repositioning may delay addressing a serious issue. CN: Physiological adaptation; CL: Synthesize