Nokea
The charge nurse is making assignments for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take?
- A. Change the nurse's assignment to another client
- B. Explain to the nurse that there is no risk to the client
- C. Ask the nurse if the chickenpox have scabbed
- D. Ask the nurse if she has ever had the chickenpox
Correct Answer: D
Rationale: Asking if the nurse has had chickenpox determines her immunity, as non-immune nurses risk transmitting varicella to an immunocompromised leukemia patient.
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The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
- A. Mild nausea.
- B. Hot flashes.
- C. Vaginal bleeding.
- D. Hair thinning.
Correct Answer: C
Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. The nurse realizes that the medication is having a therapeutic effect when the following is noted:
- A. There is an absence of peristalsis.
- B. The number of diarrhea stools decreases.
- C. Cramping in the abdomen has increased.
- D. Abdominal girth size increases.
Correct Answer: B
Rationale: Lomotil is an antidiarrheal that slows intestinal motility, reducing the frequency of diarrhea stools, indicating its therapeutic effect.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are 2 minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are 5 minutes apart.
Correct Answer: D
Rationale: Contractions 5 minutes apart indicate the onset of active labor, prompting further evaluation.
A woman has undergone a mastectomy of her right breast and has been brought to the recovery unit. The nurse explains that the client should
- A. keep her right arm elevated on a pillow.
- B. keep her right arm elevated above her head.
- C. keep her right arm level with the heart.
- D. keep her right arm slightly lower than her heart.
Correct Answer: A
Rationale: Elevating the arm on a pillow reduces lymphedema risk post-mastectomy by promoting lymphatic drainage.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself.
- B. She pulls a toy behind her.
- C. She can build a tower of eight blocks.
- D. She can copy a horizontal or vertical line.
Correct Answer: B
Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.