Nokea
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
- A. To the client from sources outside the client's environment.
- B. From the client to health care personnel, visitors, and other clients.
- C. By using special techniques to dispose of contaminated materials.
- D. By using special techniques to handle the client's linens and personal items.
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
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A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
- A. Use a heating pad under the right arm.
- B. Place ice on the area after each treatment.
- C. Apply deodorant only under the left arm.
- D. Use a soft washcloth to gently cleanse the area.
Correct Answer: C
Rationale: Applying deodorant only under the left arm avoids irritation to the radiated right axilla, which is sensitive and prone to skin reactions during treatment.
A client is eligible for patient-controlled analgesia (PCA) when:
- A. A family member is able to assist with self-dosing.
- B. There is a court-appointed advocate to assist with self-dosing.
- C. The client has the ability to self-dose.
- D. There is a nurse to assist with self-dosing.
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
- A. Provide essential fatty acids.
- B. Provides extra carbohydrates.
- C. Promotes effective metabolism of glucose.
- D. Maintains a normal body weight.
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan?
- A. The client promises to do pursed-lip breathing at home.
- B. The client states actions to reduce pain.
- C. The client says that he will use oxygen via a nasal cannula at 5 L/minute.
- D. The client agrees to call the physician if dyspnea on exertion increases.
Correct Answer: D
Rationale: Calling the physician for increased dyspnea on exertion shows understanding of when to seek help, a key part of COPD management. Pursed-lip breathing is helpful but less specific. Pain is not a primary COPD issue. High-flow oxygen (5 L/min) may suppress respiratory drive.
The nurse should assess the client with Ménière'sdisease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply.
- A. Antihistamines.
- B. Antiemetics.
- C. Diuretics.
- D. Non-steroidal anti-inflammatory drugs (NSAIDs).
- E. Antipyretics.
Correct Answer: A,B,C
Rationale: Common medications for Ménière'sdisease include antihistamines (e.g., meclizine) to reduce vertigo, antiemetics to control nausea, and diuretics to reduce inner ear fluid, all aimed at symptom management.