Nokea
The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?
- A. Obtain a soft diet for the client.
- B. Encourage frequent mouth care.
- C. Cleanse the tongue and mouth with swabs.
- D. Administer a topical analgesic per protocol.
Correct Answer: B
Rationale: Encouraging frequent mouth care is the best initial action to prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris, and moisturizing the oral tissues.
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A patient is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- A. Pupillary changes to ipsilateral dilation.
- B. Left-sided facial drooping and dysphagia.
- C. Orientation to person and place only.
- D. Unequal bilateral hand grip strengths.
Correct Answer: A
Rationale: Pupillary changes to ipsilateral dilation indicate increased intracranial pressure, which is a life-threatening complication of stroke. The nurse should notify the physician and prepare for emergency measures.
A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Gastroccult positive emesis.
- B. Strong foul smelling flatus.
- C. Complaint of poor night vision.
- D. Loose bowel movements.
Correct Answer: A
Rationale: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia has a CD4+ T cell count of 200 cells/mm³ (20%). The client asks the nurse why they have these recurring massive infections. Which pathophysiological mechanism should the nurse describe in response to this client's question?
- A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
- B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages.
- C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
- D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
Correct Answer: B
Rationale: Inadequate numbers of CD4+ T cells impair cellular immunity, making the client susceptible to opportunistic infections like Pneumocystis jiroveci pneumonia due to HIV infection.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.
A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
- A. Return for periodic liver function studies.
- B. Massage joints to relax muscles and decrease pain.
- C. Limit use of mobility equipment to avoid muscle atrophy.
- D. Substitute natural fruit juices for carbonated drinks.
Correct Answer: A
Rationale: Returning for periodic liver function studies is important because colchicine and indomethacin can cause liver toxicity, which should be monitored through regular blood tests.