Nokea
The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?
- A. Use of alcohol.
- B. Frequent use of mouthwash.
- C. Lack of vitamin B12.
- D. Lack of regular teeth cleaning by a dentist.
Correct Answer: A
Rationale: Alcohol use is a well-established primary risk factor for oral cancer, often acting synergistically with tobacco use. Frequent mouthwash use, vitamin B12 deficiency, and lack of dental cleanings are not primary risk factors for oral cancer.
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After an inguinal herniorrhaphy, the nurse should assess the client carefully for which of the following likely complications?
- A. Pneumonia.
- B. Deep vein thrombosis.
- C. Paralytic ileus.
- D. Urine retention.
Correct Answer: D
Rationale: Urine retention is a likely complication after inguinal herniorrhaphy due to anesthesia, pain, or surgical manipulation near the bladder. Pneumonia, deep vein thrombosis, and paralytic ileus are less specific to this surgery. CN: Physiological adaptation; CL: Analyze
The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?
- A. Low-pressure alarm
- B. Increased blood glucose
- C. Diminished lung sounds
- D. Hemoglobinuria
Correct Answer: D
Rationale: Hemoglobinuria (blood in the urine) is a hallmark of a hemolytic transfusion reaction, indicating red blood cell destruction. Low-pressure alarms relate to ventilator issues, increased glucose is unrelated, and diminished lung sounds may suggest other issues but not specifically transfusion reactions.
A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
Following a laryngectomy, the nurse notices that the client has saliva collecting beneath the skin flaps. This finding is indicative of which of the following?
- A. Skin necrosis.
- B. Carotid artery rupture.
- C. Stomal Stenosis.
- D. Development of a fistula.
Correct Answer: D
Rationale: Saliva collecting beneath skin flaps post-laryngectomy indicates a fistula, where saliva leaks from the pharynx or esophagus into surrounding tissues, requiring immediate attention.
When planning to move a person with a possible spinal cord injury, the nurse should direct the team to:
- A. Limit movement of the arms by wrapping them next to the body.
- B. Move the person gently to help reduce pain.
- C. Immobilize the head and neck to prevent further injury.
- D. Cushion the back with pillows to ensure comfort.
Correct Answer: C
Rationale: Immobilizing the head and neck prevents exacerbation of a spinal cord injury during movement.