Nokea
Ramona Gunther, 18, was diagnosed with Stage II Hodgkins disease and is preparing to receive external radiation therapy. She tells the nurse she is scared 'about having to get radiation treatments all over my body.' Which of the following is the most appropriate response?
- A. The dose will be very low based on the disease staging.
- B. With Stage II, you'll only have radiation over half your body.
- C. I know it's scary, but it will help to decrease the potential of fractures.
- D. You know you don't have to worry about being radioactive.
Correct Answer: B
Rationale: The dose of radiation is not based on the staging of the disease alone, and there is not enough information to know that the dose will be low. With Stage II, the involved lymph nodes are all on the same side of the diaphragm, so the radiation will be given on that part of the body. The potential of fractures occurs because of the cancer, but the radiation is not given for that reason. She has not stated that she's afraid of being radioactive, so this answer does not address her concern.
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A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
- A. Elevate the head of the client's bed.
- B. Measure and compare cuff pressures.
- C. Place the client on NPO status.
- D. Request a swallow study for the client.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Tracheostomy cuff should be inflated to prevent aspiration.
2. Food particles indicate cuff leakage.
3. Measuring cuff pressure ensures proper sealing.
4. Prevents aspiration and respiratory complications.
Summary:
A: Elevating the head is beneficial but doesn't address cuff leakage.
C: NPO status is extreme and unnecessary without confirmation of aspiration risk.
D: Swallow study is for assessing swallowing function, not related to cuff pressure.
What should the nurse closely monitor for in a client who has undergone surgery for otosclerosis?
- A. Hypotension
- B. Nausea and vomiting
- C. Decreased urine output
- D. Abnormal facial nerve function
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?
- A. Oxygen saturation of 91%
- B. Respiratory rate of 10 breaths per minute
- C. Client reports shortness of breath
- D. Use of accessory muscles
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. In a client with COPD, a respiratory rate of 10 breaths per minute indicates severe respiratory depression and impending respiratory failure. Immediate intervention is necessary to prevent hypoxia and respiratory arrest. Oxygen saturation of 91% (choice A) is low but not as critical as a low respiratory rate. Shortness of breath (choice C) is expected in COPD but does not indicate immediate danger. Use of accessory muscles (choice D) is a sign of respiratory distress, but a low respiratory rate is more concerning for imminent respiratory failure.
The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to:
- A. Check for subcutaneous emphysema in the upper torso.
- B. Reposition the client to a position of comfort.
- C. Call the health care provider as soon as possible.
- D. Check for any increase in the amount of thoracic drainage.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Steps to prevent a pressure ulcer may include
- A. Not disturbing the patient.
- B. Changing the position of a bedbound patient every 4 hours.
- C. Vigorously rubbing the skin with alcohol.
- D. Avoiding pressure on the heels of a bedbound patient.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.