Nokea
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will the nurse expect to be included in the teaching plan?
- A. TV or telephone use will not be allowed while the implant is in place.
- B. A Foley catheter is usually inserted.
- C. A high fiber diet is recommended.
- D. Excretions will be considered radioactive.
Correct Answer: B
Rationale: A catheter allows urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, so answer A is incorrect. The client is placed on a low residue diet, so answer C is incorrect. The client's radiation is not internal; therefore, there are no special precautions with excretions, making answer D incorrect.
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While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:
- A. Check the doctor's orders for an antipyretic.
- B. Ask the client whether he has received any medication for his fever.
- C. Call the nurse at home to validate whether the medication was given.
- D. Retake the client's temperature.
Correct Answer: D
Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.
The nurse is reinforcing teaching about oral hydrocortisone for a client with newly diagnosed primary adrenal insufficiency (i.e., Addison disease). Which of the following information should the nurse reinforce? Select all that apply.
- A. Discontinue hydrocortisone if you have mood changes or disruptions in behavior
- B. Report even a low-grade fever to the health care provider immediately
- C. Report signs of hyperglycemia, including increased urine, hunger, and thirst
- D. The dose of hydrocortisone may need to be increased during times of illness or injury
- E. This medication should be taken on an empty stomach to enhance absorption
Correct Answer: B,C,D
Rationale: Reporting fever, hyperglycemia, and adjusting doses during illness are critical for Addison disease management. Hydrocortisone should not be stopped abruptly, and food enhances absorption.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
The nurse is reinforcing teaching about measures to prevent the transmission of hepatitis A for a group of clients at an outpatient treatment facility for substance use disorders. Which of the following information would be most important for the nurse to include?
- A. Avoid drinking tap water at home
- B. Do not share needles if you inject recreational substances
- C. Practice safe sex by using condoms
- D. Wash your hands thoroughly after toileting and before eating
Correct Answer: D
Rationale: Hepatitis A is transmitted via the fecal-oral route, making handwashing after toileting and before eating critical. Tap water, needle sharing, and sex are not primary transmission modes for hepatitis A.