Nokea
The client is receiving chemotherapy for breast cancer. Which instruction should the nurse include to prevent infection?
- A. Avoid crowds and people with colds.'
- B. Take your temperature twice a week.'
- C. Eat only well-cooked meats.'
- D. Use a soft toothbrush for oral care.'
Correct Answer: A
Rationale: Chemotherapy causes immunosuppression, increasing infection risk. Avoiding crowds and sick individuals reduces exposure to pathogens. The other measures are helpful but less effective at preventing infection.
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The nurse has an order for the administration of intravenous heparin. The medication should be administered using a/an:
- A. Metered chamber
- B. Infusion controller
- C. Intravenous filter
- D. Three-way stopcock
Correct Answer: B
Rationale: Intravenous heparin requires precise dosing to maintain therapeutic anticoagulation. An infusion controller (e.g., infusion pump) ensures accurate delivery. A metered chamber is for fluids, an IV filter is for removing particles, and a stopcock is for multiple infusions, not precise control.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?
- A. He will attend four consecutive group educational sessions on substance abuse.
- B. He will name activities that he would most likely be involved in posttreatment.
- C. He will meet with his family in counseling sessions and discuss his feelings.
- D. He will be able to deal with his feelings through participation in group therapy sessions.
Correct Answer: D
Rationale: This expected outcome is specific as related to attendance, but not specific as related to outcome criteria. Stating activities does not guarantee involvement. This goal may help the recovery process, but post counseling behavior is not addressed. This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
- A. Placing the client in a prone position
- B. Maintaining strict bed rest for 24 hours
- C. Offering a clear liquid diet
- D. Instructing the client to keep his head bowed when sitting upright
- E. Applying an eye patch to protect the affected eye from light
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (A) to keep oil against the retina, head bowed when upright (D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (B) is not strict, and diet (C) progresses as tolerated.
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
- A. Administering bronchodilators
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.