Nokea
The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will apply an ice pack to the treatment site if my skin begins to burn.
- B. I will rub baby oil on the site after each treatment to prevent dry skin.
- C. I will use extra measures to protect my skin from sun exposure.
- D. I will wash the treatment site with lukewarm water and mild soap.
- E. I will wear soft, loose-fitting clothing.
Correct Answer: C,D,E
Rationale: Sun protection (C), gentle washing (D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (A) can damage skin, and baby oil (B) may irritate or trap radiation.
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The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room?
- A. 35-year-old with blood loss anemia and a 28-year-old diagnosed with severe anorexia nervosa
- B. 50-year-old who had a bowel resection 2 days ago and a 40-year-old diagnosed with pneumonia
- C. 60-year-old who had a total hip arthroplasty yesterday and a 58-year-old with fever of unknown origin
- D. 60-year-old with gastroenteritis and a 70-year-old with diarrhea and vomiting related to chemotherapy
Correct Answer: D
Rationale: Clients with gastroenteritis and chemotherapy-induced diarrhea (D) have similar non-airborne conditions, making them suitable roommates. Pneumonia (B) and fever of unknown origin (C) pose infection risks. Anemia and anorexia (A) are unrelated but not optimal.
A client scheduled for a computerized axial tomography (CAT) using a contrast medium scan of the brain should be assessed for:
- A. Claustrophobia
- B. Iodine sensitivity
- C. Liver function
- D. Metallic implants
Correct Answer: B
Rationale: Contrast medium often contains iodine, so assessing for iodine sensitivity prevents allergic reactions. Claustrophobia, liver function, and implants are secondary concerns.
A client with insulin-dependent diabetes takes 20 units NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
- A. 8 a.m.
- B. 10 a.m.
- C. 3 p.m.
- D. 5 a.m.
Correct Answer: C
Rationale: NPH insulin peaks 6-12 hours after administration (1-3 p.m.), making 3 p.m. the time to watch for hypoglycemia. Other times are outside the peak window.
The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?
- A. Discontinue the exchange and collect a peritoneal fluid specimen for culture and sensitivity.
- B. Warm the remaining dialysate fluid and increase the dwell time of the exchange.
- C. Administer a dose of oxycodone prescribed PRN for the client.
- D. Place the client in the high-Fowler position in bed.
Correct Answer: A
Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (A). Warming dialysate (B), pain medication (C), and positioning (D) do not address the infection.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.