Nokea
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- A. Using oil- or cream-based soaps
- B. Flossing between the teeth
- C. The intake of salt
- D. Using an electric razor
Correct Answer: B
Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.
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Ideally, the first dose of what vaccine is given at birth?
- A. IPV
- B. Hib
- C. DTaP
- D. hepatitis B
Correct Answer: D
Rationale: The hepatitis B vaccine is recommended at birth to prevent perinatal transmission and establish early immunity.
The nurse is teaching the mother of an infant with eczema. Which of the following instructions should be included in the nurse's teaching?
- A. Dress the infant warmly to prevent undue chilling
- B. Cut the infant's fingernails and toenails regularly
- C. Use bubble bath instead of soap for bathing
- D. Wash the infant's clothes with mild detergent and fabric softener
Correct Answer: B
Rationale: Cutting nails regularly prevents scratching, which can worsen eczema and lead to infections in affected skin areas.
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
- A. prepare to administer IV fluids
- B. notify the health care provider
- C. order a mechanical soft diet for the client
- D. administer the next dose of lithium when it is due
- E. observe the client for confusion and slurred speech
Correct Answer: A, B, E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity (therapeutic range: 0.6–1.2 mEq/L). The nurse should prepare IV fluids, notify the provider, and monitor for symptoms like confusion and slurred speech. A soft diet is unnecessary, and the next dose should be held.
A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.