Nokea
During the removal of a radium implant, it is MOST important for the nurse to take which of the following actions?
- A. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps.
- B. Handle the radium carefully using forceps and rubber latex gloves.
- C. Chart the date and time of removal along with the total time of implant treatment.
- D. Double-bag the radium implant before the person from radiology removes it from the room.
Correct Answer: C
Rationale: important that accurate documentation be maintained on the internal radium implant
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The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?
- A. Encourage dependency with activities of daily living.
- B. Provide flexibility in schedules due to his confusion.
- C. Limit reminiscing due to poor memory.
- D. Speak slowly in a face-to-face position.
Correct Answer: D
Rationale: is most effective when communicating with an elderly client
The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?
- A. Prevent iron deficiency anemia.
- B. Decrease touch to prevent overstimulation.
- C. Provide feedings via gavage to decrease energy expenditure.
- D. Replace vitamins depleted as a result of poor maternal diet.
Correct Answer: D
Rationale: frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion