Nokea
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
- A. I understand the need to avoid sharing food or utensils with others.
- B. My children will miss my hugs and kisses for the next week.
- C. I'll travel for a couple of weeks to prevent my family from receiving radiation from me.
- D. I understand the need to flush the toilet with the lid closed two to three times after each use.
Correct Answer: C
Rationale: Traveling for weeks is excessive and unnecessary. Avoiding shared items, limiting close contact, and double flushing are appropriate to reduce radiation exposure.
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The nurse performs a head-to-toe assessment on an assigned client. Which of the following client findings are examples of subjective data? Select all that apply.
- A. The client reports feeling nauseated.
- B. The client's lower extremities are swollen.
- C. The client expresses nervousness about test results.
- D. The client reports that their leg is itching.
- E. The client rates pain at a 6 on a scale of 1 to 10.
- F. The client vomits twice after eating dinner.
Correct Answer: A,C,D,E
Rationale: Subjective data are client-reported, like nausea, nervousness, itching, and pain rating. Swelling and vomiting are objective, observed by the nurse.
The purpose of a health assessment is to:
- A. Obtain subjective and objective data
- B. Outline appropriate care
- C. Determine whether interventions are effective
- D. Intervene to correct difficulties
Correct Answer: A
Rationale: Health assessments collect subjective and objective data to inform care planning. Outlining care, evaluating interventions, or correcting issues are subsequent steps.
The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply.
- A. Providing a meal tray
- B. Changing bed linens
- C. Replacing a suction canister
- D. Obtaining vital signs
- E. Providing range of motion exercises
Correct Answer: C,D
Rationale: Two client identifiers are required for procedures that involve direct client intervention with potential for error, such as replacing a suction canister (invasive equipment) and obtaining vital signs (recorded in medical records). Providing a meal tray, changing bed linens, and range of motion exercises do not typically require two identifiers.
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
The nurse is caring for a client with a jejunostomy tube receiving intermittent enteral feedings. Which intervention would reduce this client's aspiration risk?
- A. Flush tubing with 10 mL water after feeding is completed
- B. Assess the client's gag reflex prior to feeding
- C. Assess blood glucose every 6 hours
- D. Position the client in semi-Fowler's during and after the feeding
Correct Answer: D
Rationale: Positioning the client in semi-Fowler's (30-45 degrees) during and after feeding reduces aspiration risk by using gravity to prevent gastric contents from refluxing.