Nokea
The nurse is caring for a woman who is receiving internal radiation for cancer of the cervix. Which nursing action will do most to reduce the risk of radiation exposure to other clients?
- A. Keep the door to the client's room closed.
- B. Place the client in the bed closest to the outside window.
- C. Place the client in a room close to the nurse's station for continuous observation.
- D. Place a 'Do not enter' sign on the door to the client's room.
Correct Answer: A
Rationale: Keeping the door closed minimizes radiation exposure to others by containing emissions. Bed placement or signs are less effective, and observation doesn't reduce exposure.
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A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck.
- A. Which PRN medication should the nurse expect to give for a client with extrapyramidal side effects from perphenazine?
- B. Promazine (Sparine).
- C. Biperiden (Akineton).
- D. Thiothixene (Navane).
- E. Haloperidol (Haldol).
Correct Answer: B
Rationale: Biperiden, an antiparkinsonian agent, counteracts extrapyramidal side effects (e.g., dystonia, stiffness) caused by antipsychotics like perphenazine. Promazine, thiothixene, and haloperidol are antipsychotics that could worsen these side effects.
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
Which of the following should the nurse include in his teaching plan for the client taking Vasopressin (Lypressin)?
- A. The client will need to take her medication with meals.
- B. The client will need to learn how to check the specific gravity of her urine.
- C. The client will need to modify her daily activities.
- D. The client will need to learn the proper method of drug administration.
Correct Answer: D
Rationale: Vasopressin is often administered nasally or by injection, so teaching the proper administration method is essential.
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
The physician has ordered Prednisone 50 mg daily to promote diuresis in a client with nephrotic syndrome. The nurse should administer the medication:
- A. In a single dose at bedtime
- B. With a snack or glass of milk
- C. With water to promote absorption
- D. Prior to arising in the morning
Correct Answer: B
Rationale: Prednisone, a steroid, should be given with a snack or meal to prevent gastric irritation. Answer C would cause pain and gastric upset, making it incorrect. Answers A and D do not include providing food with the medication, so they are incorrect.