Nokea
The nurse is caring for a client with a history of breast cancer who is receiving radiation therapy. Which of the following instructions should the nurse include in the client's teaching?
- A. Apply lotion to the radiated area immediately after treatment.
- B. Avoid exposing the radiated area to sunlight.
- C. Wash the radiated area with soap and water daily.
- D. Wear tight clothing over the radiated area.
Correct Answer: B
Rationale: Avoiding sunlight exposure protects the radiated skin from further damage and reduces irritation.
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As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus' presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus' presenting part to the anterior, posterior, right or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus' presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct Answer: D
Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.
Which intervention would you expect to render to the client in a sickle cell anemia crisis?
- A. The administration of a thrombolytic medication
- B. The administration of hydroxyurea
- C. Placing the client in the Trendelenburg position
- D. Placing the client in the lithotomy position
Correct Answer: B
Rationale: Hydroxyurea is used in sickle cell anemia to reduce the frequency of crises by increasing fetal hemoglobin, which helps prevent sickling of red blood cells.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
A primigravid client at 10 weeks' gestation tells the nurse that she eats fruits and vegetables but isn't fond of them. After teaching the client about possible serving sizes, the nurse determines that the teaching has been successful when the client states that one serving of fruit is equivalent to which of the following?
- A. One-fourth of a cantaloupe
- B. 3 oz of vegetable juice cocktail
- C. Three tomatoes
- D. One raw apricot
Correct Answer: A
Rationale: One serving of fruit is equivalent to one-fourth of a cantaloupe. The client needs $6 \mathrm{oz}$ of a vegetable juice cocktail, two tomatoes, or two raw apricots to meet one fruit serving.
A client with a history of peptic ulcer disease is admitted with abdominal pain. The nurse should include which of the following in the plan of care?
- A. Administer pantoprazole as prescribed.
- B. Encourage a high-fiber diet.
- C. Administer ibuprofen for pain.
- D. Position the client supine.
Correct Answer: A
Rationale: Pantoprazole reduces acid production, promoting ulcer healing.