Nokea
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.
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The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
- A. Cyanocobalamine
- B. Protamine sulfate
- C. Streptokinase
- D. Sodium warfarin
Correct Answer: B
Rationale: Protamine sulfate neutralizes heparin's anticoagulant effect.
The nurse knows that a 60-year-old female client's susceptibility to osteoporosis is most likely related to:
- A. Lack of exercise
- B. Hormonal disturbances
- C. Lack of calcium
- D. Genetic predisposition
Correct Answer: B
Rationale: Hormonal changes, particularly estrogen loss post-menopause, are the primary cause of osteoporosis in women.
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be served with disposable utensils
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed, single-serving packages
Correct Answer: D
Rationale: Sealed, single-serving foods reduce infection risk in neutropenic patients.
When administering a tuberculin skin test, the nurse should insert the needle at a:
- A. 15° angle
- B. 30° angle
- C. 45° angle
- D. 90° angle
Correct Answer: A
Rationale: A 15° angle is used for intradermal injections like the tuberculin skin test to ensure proper placement in the dermis.
The nurse is preparing to administer a unit of red blood cells (RBCs) to an anemic client. From starting the infusion (puncturing the blood pack) to completion, infusion of the pack should occur within which time period?
- A. 8 hours
- B. 6 hours
- C. 4 hours
- D. 2 hours
Correct Answer: C
Rationale: RBC transfusions must be completed within 4 hours to minimize bacterial growth and ensure safety.