Nokea
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.
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The nurse is talking with a postpartum client about resuming sexual activity after childbirth. The client had an uncomplicated vaginal delivery 2 weeks ago. Which statement by the client requires follow-up?
- A. I do not need to use condoms to prevent pregnancy until my menses returns
- B. "I should avoid resuming sexual intercourse until my vaginal bleeding has stopped."
- C. I should expect to experience vaginal dryness and can use water-soluble lubricants
- D. I will try to feed my baby before my partner and I engage in sexual activity
Correct Answer: A
Rationale: Ovulation can occur before menses returns, so condoms are needed to prevent pregnancy. Vaginal dryness is common, and feeding before sex reduces interruptions, both correct.
The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?
- A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
- B. Client is lying with knees drawn up to the abdomen to alleviate pain
- C. Temperature is 102.2°F (39°C) with increasing abdominal pain
- D. Five large, liquid stools are yellow and foul-smelling
Correct Answer: C
Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.
The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?
- A. Administer insulin lispro per protocol and insulin NPH
- B. Contact the client's health care provider
- C. Obtain a urine specimen to check for ketones
- D. Recheck the client's capillary blood glucose level
Correct Answer: B
Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.