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The nurse is caring for a woman who had a mastectomy following a diagnosis of breast cancer. When the nurse enters the room, the curtains are drawn, and the client is lying with her body turned toward the wall away from the nurse. When the nurse approaches her, the client says, 'Just leave me alone. I'm no use to anyone. I'm not even a real woman.' How should the nurse respond?
- A. Leave the room
- B. Open the curtains
- C. Say, 'You sound upset.'
- D. Say, 'Women are more than breasts.'
Correct Answer: C
Rationale: Acknowledging the client's feelings is an appropriate response to this common grief reaction following the loss of a body part. Leaving the room would reinforce the client's perception that she is useless. Opening the curtains does not address the client's concerns; it merely forces the nurse's perception of appropriateness on the client. Saying 'Women are more than breasts' is not an appropriate response to the client. The nurse should recognize the client's feelings, not put her down.
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The nurse is caring for a client who is receiving a continuous IV infusion of furosemide (Lasix) for heart failure. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication of furosemide, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The first nursing action should be to
- A. Notify the primary care provider immediately
- B. Suggest in-patient psychiatric care
- C. Respect the client's confidential disclosure
- D. Phone the family to warn them of the risk
Correct Answer: A
Rationale: Notify the primary care provider immediately. The client’s suicidal intent and plan require immediate intervention by the healthcare team.
The parents of an infant ask the nurse in the physician's office what diseases the DPT shot protects against. What should the nurse include when replying?
- A. Diarrhea, polio, and typhoid
- B. Diphtheria, whooping cough, and tetanus
- C. Diarrhea, pertussis, and typhus
- D. Diphtheria, paralysis, and tetany
Correct Answer: B
Rationale: The DPT (DTaP) vaccine protects against diphtheria, pertussis (whooping cough), and tetanus. The other options include incorrect diseases.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
- A. Which behavior by the LPN/LVN indicates proper wet-to-dry dressing change technique?
- B. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- C. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- D. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- E. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.
The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. White blood cell count of 3,000/mm^3.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious side effect of carbamazepine, increasing infection risk and requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.