Nokea
The client diagnosed with oat cell carcinoma of the lung tells the nurse, 'I am so tired of all this. I might as well just end it all.' Which statement should be the nurse's first response?
- A. Say, 'This must be hard for you. Would you like to talk?'
- B. Tell the HCP of the client's statement.
- C. Refer the client to a social worker or spiritual advisor.
- D. Find out if the client has a plan to carry out suicide.
Correct Answer: A
Rationale: Acknowledging feelings and offering to talk (A) opens communication for suicidal ideation. Notifying HCP (B), referring (C), and assessing plans (D) follow.
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Which agents should the nurse suspect as being the cause of the victims' symptoms? Select all that apply.
- A. Anthrax
- B. Sarin gas
- C. Smallpox
- D. Radiation
- E. Cyanide
- F. Ebola virus
Correct Answer: B, E
Rationale: Sarin gas and cyanide are chemical agents that can cause rapid onset of dyspnea, weakness, and nausea, consistent with the symptoms described.
An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
- A. Keep him NPO for eight hours
- B. Prepare him to go to the operating room
- C. Explain the procedure to him
- D. Administer anticholinergic and analgesic as ordered
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures the client understands what to expect during thoracentesis.
When the nurse is instructing the client on the effectiveness of oseltamivir (Tamiflu), which of the following instruction points is essential?
- A. Tamiflu must be started within 12 to 24 hours of the first symptoms.
- B. Tamiflu must be taken on an empty stomach to aid in absorption.
- C. Tamiflu affects the liver; liver enzymes are assessed before administration.
- D. Tamiflu is most effective when administered intranasally.
Correct Answer: A
Rationale: Oseltamivir is most effective when started within 12 to 24 hours of symptom onset, as it inhibits viral replication early.
Which time of day is best for the nurse to obtain a sputum specimen from the client?
- A. Before bedtime
- B. After a meal
- C. Between meals
- D. On awakening
Correct Answer: D
Rationale: Sputum is most concentrated and easier to collect on awakening due to accumulation overnight.
Select all the factors regarding a deep vein thrombosis that are included in Virchow's Triad:
- A. Hypocoagulability
- B. Atherosclerosis
- C. Endothelial damage
- D. Stasis of venous blood
- E. Excessive coagulability
- F. Increased venous blood flow
Correct Answer: C,D,E
Rationale: Virchow's Triad details the THREE factors (hence why it called a triad) for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage.