Nokea
Nurse Jane is providing care for a client with superior vena cava syndrome. Which of the following interventions would be the priority?
- A. Elevate the head of the bed
- B. Administer steroids as prescribed
- C. Provide supplemental oxygen
- D. Administer diuretics as prescribed
Correct Answer: A
Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed can help reduce the pressure on the superior vena cava, improve venous return, and facilitate breathing in clients with superior vena cava syndrome. Administering steroids (Choice B) may be necessary in some cases, but it is not the priority in the immediate care of a client with superior vena cava syndrome. Providing supplemental oxygen (Choice C) may help improve oxygenation but does not directly address the underlying issue of venous congestion. Administering diuretics (Choice D) may be contraindicated as it can further decrease preload and worsen the condition in superior vena cava syndrome.
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The school nurse is teaching a nutrition class in the local high school. One student states that he has heard that certain foods can increase the incidence of cancer. The nurse responds, Research has shown that certain foods indeed appear to increase the risk of cancer. Which of the following menu selections would be the best choice for potentially reducing the risks of cancer?
- A. Smoked salmon and green beans
- B. Pork chops and fried green tomatoes
- C. Baked apricot chicken and steamed broccoli
- D. Liver, onions, and steamed peas
Correct Answer: C
Rationale: The correct choice is 'Baked apricot chicken and steamed broccoli' because fruits and vegetables have been shown to reduce the risk of cancer. Option A, smoked salmon and green beans, although a healthy choice, does not incorporate as many cancer-fighting foods as the correct answer. Option B, pork chops and fried green tomatoes, contains fried food which is associated with increased cancer risk. Option D, liver, onions, and steamed peas, includes organ meats which are not considered beneficial for reducing cancer risk.
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important?
- A. Assess blood pressure and pulse.
- B. Attach the client to a pulse oximeter.
- C. Have the client rate his or her pain.
- D. Facilitate urgent radiation therapy.
Correct Answer: A
Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.
A nurse is teaching a patient with chronic lymphocytic leukemia (CLL) about potential complications. Which complication should the nurse emphasize?
- A. Infection
- B. Hemorrhage
- C. Fatigue
- D. Splenomegaly
Correct Answer: A
Rationale: The correct answer is A: Infection. Patients with chronic lymphocytic leukemia (CLL) are at a significant risk of infection due to their compromised immune system. Emphasizing the importance of infection prevention and prompt treatment is crucial in the care of these patients. Choice B, Hemorrhage, is less common in CLL compared to other types of leukemia. Choice C, Fatigue, is a common symptom but not a complication that poses immediate risks. Choice D, Splenomegaly, is a common finding in CLL but not the most critical complication to emphasize regarding patient education.
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
- A. Encouraging fluids
- B. Providing frequent oral care
- C. Coughing and deep breathing
- D. Monitoring the red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Encouraging fluids. In a client with multiple myeloma, encouraging fluids is a priority intervention to prevent kidney damage from high calcium levels. Adequate hydration helps maintain renal function and prevents complications. Providing frequent oral care (Choice B) is essential for clients at risk of mucositis or oral infections, such as those undergoing chemotherapy. Coughing and deep breathing exercises (Choice C) are commonly used for clients at risk of respiratory complications, like postoperative patients. Monitoring the red blood cell count (Choice D) is important for conditions like anemia but is not the priority in a client with multiple myeloma, where fluid management is crucial.
The patient is anxious about subjection to radiation therapy. Which of the following statements of the student nurse requires additional teaching?
- A. Teletherapy is radiation from an external source.
- B. Brachytherapy can be administered via oral or IV.
- C. Brachytherapy is a radiation from inside the patient's body.
- D. Chemotherapy is effective in killing all cancer cells.
Correct Answer: D
Rationale: The correct answer is D because the statement 'Chemotherapy is effective in killing all cancer cells' is incorrect. Chemotherapy does not kill all cancer cells and is not the same as radiation therapy. Chemotherapy targets rapidly dividing cells, including cancer cells, but it may not kill every single cancer cell. It is important for the student nurse to understand and communicate this distinction to the patient. Choices A, B, and C provide accurate information about teletherapy, brachytherapy, and chemotherapy, respectively, and do not require additional teaching.