Nokea
Following a bone marrow transplant, the patient has an increased risk for
- A. Bleeding.
- B. Infection.
- C. Clot formation.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Immunosuppression increases the risk of infection post-transplant.
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A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?
- A. Rest in a side-lying position after the tube is removed.
- B. Use the incentive spirometer every 4 hours after the tube is removed.
- C. Avoid speaking for extended periods.
- D. Vital signs will be monitored by a nurse every 15 minutes in the first hour after the tube is removed.
Correct Answer: C
Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications.
Step-by-step rationale:
1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage.
2. It is essential to allow the airway to recover and prevent irritation or inflammation.
3. Resting the voice can aid in the healing process and reduce the risk of complications.
4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest.
5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications.
6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.
What is the most common cause of orbital cellulitis?
- A. Sinus infection
- B. Trauma
- C. Foreign body
- D. All of the above
Correct Answer: A
Rationale: Sinus infections are the most frequent source of orbital cellulitis due to proximity and anatomical connections.
Jill Means, 36, has had a vaginal radium implant placed as one of the treatments for her cervical cancer. She calls to tell you that during a coughing spell it has 'been pushed out'. You should:
- A. place signs on the door stating radioactivity danger.
- B. have Jill reinsert the applicator like a tampon.
- C. call the physician and apprise him of the situation.
- D. use forceps to place the applicator in the receptacle.
Correct Answer: D
Rationale: Signs should be placed on the door after the implant has been done, and not just when the implant is dislodged. By picking the applicator up, Jill would experience burns on her fingers/hands that would be avoidable, so need to teach her not to do so. The applicator has been contaminated, it would not be replaced in any case. Calling the physician and apprising him would certainly be necessary, but would be done after the applicator has been taken care of. Lead containers should be available to place the applicator in, and forceps would be used to do so to protect from radiation burns.
What cultural elements should a nurse ask about or observe when performing a cultural assessment on a client?
- A. Health beliefs,dietary preferences and communication styles.
- B. Only health beliefs.
- C. Only dietary preferences.
- D. Only communication styles.
Correct Answer: A
Rationale: Comprehensive cultural assessments include health beliefs, dietary preferences, and communication styles to tailor care appropriately.
How can a nurse provide culturally competent care to all individuals?
- A. Become familiar with physical differences among ethnic groups.
- B. Learn to speak a second language.
- C. Develop strategies to avoid cultural imposition.
- D. Consult the client about ways to solve health problems.
Correct Answer: C
Rationale: Avoiding cultural imposition ensures respect for individual preferences and promotes inclusive care practices.