Nokea
The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following to be a late-occurring symptom of oral cancer?
- A. Warmth
- B. Odor
- C. Pain
- D. Ulcer with flat edges
Correct Answer: C
Rationale: Pain is a late symptom of oral cancer, often occurring as the disease progresses and affects surrounding tissues.
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The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a:
- A. Plastic zip-lock bag
- B. Rubber tote
- C. Paper bag
- D. Padded manila envelope
Correct Answer: C
Rationale: A paper bag allows air circulation, preventing moisture that could degrade biological evidence.
The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
- A. Anxiety
- B. Pain
- C. Knowledge deficit
- D. Altered thought process
Correct Answer: C
Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.
The nurse is caring for a client diagnosed with C. diff. The client has soiled the bed and the nurse is preparing to change it. Which action by the nurse is correct in regard to handling soiled linens that have been exposed to C. diff?
- A. throw the linens in the trash can in the soiled utility room
- B. leave the dirty linens in a bag in the client's room until he is discharged
- C. place the items in a red biohazard bag and place them in the soiled utility room
- D. place the soiled linen in a regular dirty linen bag and place in the soiled utility room
Correct Answer: D
Rationale: C. diff-contaminated linens should be placed in a regular dirty linen bag, as they are processed with high-temperature washing to kill spores, not treated as biohazard waste.
The nurse assesses a new order for a blood transfusion. The order is to transfuse 1 unit of packed red blood cells (contains 250 mL) in a 2-hour period. What will be the hourly rate of infusion?
- A. 50 mL/hr
- B. 62 mL/hr
- C. 125 mL/hr
- D. 137 mL/hr
Correct Answer: C
Rationale: To calculate the hourly rate: 250 mL ÷ 2 hours = 125 mL/hr, ensuring the transfusion is completed within the prescribed time.