Nokea
The client with Hodgkin's disease develops B symptoms. These manifestations indicate which of the following?
- A. The client has a low-grade fever (temperature lower than 100°F [37.8°C]).
- B. The client has a weight loss of 5% or less of body weight.
- C. The client has night sweats.
- D. The client probably has not progressed to an advanced stage.
Correct Answer: C
Rationale: B symptoms in Hodgkin's disease include fever (>38°C), night sweats, and weight loss (>10% of body weight). Night sweats are a hallmark symptom indicating possible disease progression.
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The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Droplet precautions.
- D. Airborne precautions.
Correct Answer: D
Rationale: Tuberculosis requires airborne precautions due to droplet nuclei transmission. Standard, contact, and droplet precautions are insufficient.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
The nurse is caring for a 78-year-old male with lung cancer who is receiving chemotherapy. The client states he is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?
- A. Local health milk and strawberries.
- B. Toast, gelatin dessert, and cookies.
- C. Broiled chicken, green beans, and cottage cheese.
- D. Steak and french fries.
Correct Answer: C
Rationale: Broiled chicken, green beans, and cottage cheese provide high protein and nutrients with low fat, which is ideal for a client with poor appetite during chemotherapy to support nutrition without being heavy.
The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINHAL).
- C. An online nursing textbook.
- D. The online policy and procedure manual at the health care agency.
Correct Answer: A
Rationale: The Cochrane Library provides high-quality, evidence-based systematic reviews, making it the most reliable resource for developing standards of care.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.