Nokea
Intra-arterial chemotherapy primarily benefits the client by applying greater concentrations of medication directly to the malignant tumor. An additional benefit of intra-arterial chemotherapy is:
- A. Prevention of nausea and vomiting
- B. Treatment of micro-metastasis
- C. Eradication of bone pain
- D. Prevention of therapy-induced anemia
Correct Answer: B
Rationale: Intra-arterial chemotherapy can treat micro-metastases by delivering high drug concentrations to the tumor and surrounding areas.
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The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:
- A. Place tape completely around the extremity, with tape ends out of the client's vision
- B. Tell him that if he pulls out the IV, it will have to be restarted
- C. Slap the client's hand when he reaches toward the IV site
- D. Apply clove hitch restraints to the client's hands
Correct Answer: A
Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.
The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: C
Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain a culture of:
- A. Blood
- B. Nasopharyngeal secretions
- C. Stool
- D. Genital secretions
Correct Answer: D
Rationale: Gonorrhea is diagnosed by culturing genital secretions.
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
- A. A tracheotomy set
- B. A padded tongue blade
- C. An endotracheal tube
- D. An airway
Correct Answer: A
Rationale: A tracheotomy set is kept at the bedside post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma.
The nurse is assessing a client upon arrival to the emergency department. Partial airway obstruction is suspected. Which clinical manifestation is a late sign of airway obstruction?
- A. Rales auscultated in breath sounds
- B. Restlessness
- C. Cyanotic ear lobes
- D. Inspiratory stridor
Correct Answer: C
Rationale: Cyanotic ear lobes indicate severe hypoxemia, a late sign of airway obstruction. Restlessness and stridor are earlier, and rales are unrelated.