Nokea
The nurse is preparing a client for cervical uterine radiation implant insertion. Which will 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 Foley catheter is inserted during cervical radiation implants to keep the bladder empty, reducing radiation exposure to nearby organs. The other options are incorrect or irrelevant.
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The nursing assistant is taking vitals for a client on mechanical ventilation. Which of the following findings should the nursing assistant report to the nurse immediately?
- A. respiratory rate 26 breaths/minute
- B. heart rate 82 beats/minute
- C. blood pressure 152/86 mmHg
- D. temperature 102.1°F
Correct Answer: D
Rationale: Fever (102.1°F) in a ventilated client suggests infection (e.g., ventilator-associated pneumonia), requiring immediate reporting.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort can cause photosensitivity, increasing the risk of skin reactions, so sunscreen use is recommended, not avoided.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.
A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse?
- A. administer oxygen at 2 L/min as ordered prn
- B. place client in a semi-Fowler's position
- C. prepare client for diagnostic tests
- D. obtain vital signs
Correct Answer: C
Rationale: Dyspnea and chest pain suggest a possible pulmonary embolism, a complication of DVT, requiring immediate preparation for diagnostic tests to confirm and treat.