Nokea
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?
- A. The client is maintained on strict bed rest
- B. The head of the bed is at 30-degree angle
- C. The client receives a complete bed bath each morning
- D. The nurse checks the applicator’s position every 4 hours
Correct Answer: B
Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator.
A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery.
C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken.
D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.
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In a client who has human immunodeficiency virus (HIV) infection, CD4+ levels are measured to determine the:
- A. Presence of opportunistic infections
- B. Extent of immune system damage
- C. Level of the viral load
- D. Resistance to antigens
Correct Answer: B
Rationale: Step-by-step rationale:
1. CD4+ cells are a type of white blood cell crucial for immune function.
2. HIV targets and destroys CD4+ cells, leading to immune system damage.
3. Measuring CD4+ levels helps determine the extent of this damage.
4. Therefore, the correct answer is B.
Summary:
A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose.
C: Level of the viral load - Measured separately from CD4+ levels.
D: Resistance to antigens - CD4+ levels do not directly indicate resistance.
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections.
- Choice B: Cognitive problems, is not directly related to lymphocyte levels.
- Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes.
- Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.
Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
- A. carbon dioxide level
- B. prothrombin time
- C. gastric pH
- D. white blood cell count
Correct Answer: B
Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
- A. A glass of water every hour until hydrated
- B. Small frequent intake of juices, broth, or milk
- C. Short-term NG replacement of fluids and nutrients
- D. A rapid IV infusion of an electrolyte and glucose solution
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Dehydration leads to electrolyte imbalances, which can exacerbate cardiac dysrhythmias.
2. Small frequent intake of fluids like juices, broth, or milk helps in gradual rehydration without overwhelming the cardiovascular system.
3. This approach allows for better absorption of fluids and nutrients, promoting hydration without causing sudden shifts in electrolyte levels.
Summary of why other choices are incorrect:
A: Just drinking a glass of water every hour may not address electrolyte imbalances or provide adequate hydration for a client with cardiac dysrhythmias.
C: NG replacement may not be necessary if the client can tolerate oral intake, and it is more invasive than needed.
D: A rapid IV infusion may lead to sudden changes in electrolyte levels, potentially worsening the dysrhythmias.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions.
Incorrect choices:
A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment.
B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management.
D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.