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 having the head of the bed at a 30-degree angle can cause the radioactive material to shift, potentially leading to an uneven distribution of radiation. This could result in harmful exposure to surrounding tissues.
A: Maintaining the client on strict bed rest is important to prevent displacement of the radioactive applicator.
C: Providing a complete bed bath each morning is necessary for hygiene and does not pose a radiation hazard.
D: Checking the applicator's position every 4 hours is essential to ensure proper placement and does not indicate a radiation hazard.
You may also like to solve these questions
A client’s blood glucose levels remain elevated despite adherence to the prescribed treatment plan. What is the nurse’s best action?
- A. Reassess the client’s diet, medication, and lifestyle habits.
- B. Increase the client’s medication dosage.
- C. Document the elevated levels and continue with the current plan.
- D. Notify the client’s family about the lack of progress.
Correct Answer: A
Rationale: The correct answer is A because reassessing the client's diet, medication, and lifestyle habits allows the nurse to identify any factors contributing to the elevated blood glucose levels. By identifying possible issues, the nurse can make necessary adjustments to the treatment plan to better manage the client's condition. Increasing medication dosage without understanding the root cause may lead to adverse effects. Simply documenting the elevated levels without taking proactive measures does not address the problem. Notifying the client's family is not the nurse's first action; the focus should be on assessing and addressing the client's needs.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
- A. Ineffective breathing pattern related to pneumonia
- B. Risk for infection related to chest x-ray procedure NursingStoreRN
- C. Risk for deficient fluid volume related to dehydration
- D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D
Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation.
Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: The correct answer is B because monitoring for swelling and heaviness of legs is essential in preventing falls, which can be caused by conditions like edema or circulatory issues. Swollen or heavy legs can affect mobility and balance, increasing the risk of falls. This intervention helps identify potential issues early and implement preventive measures.
Choice A is incorrect as monitoring for chest pain and LDL levels pertains more to cardiovascular health than fall prevention. Choice C is incorrect because monitoring postural changes in BP is important for managing hypertension, not necessarily for preventing falls. Choice D is incorrect as monitoring temperature for mild fever is more related to identifying infections rather than preventing falls.
The nurse caring for an adult client. The nurse will need to monitor for which of the following metabolic complications?
- A. hypoglycemia and hypercalcemia
- B. hyperglycemia and hyperkalemia
- C. hyperglycemia and Hypokalemia
- D. hyperkalemia and hypercalcemia
Correct Answer: C
Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice D) are less likely to be monitored together as they are not commonly seen in the same clinical context.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL in 24 hours
- B. Urine output of more than 200mL/hour
- C. Blood pressure of 90/50mmHg
- D. Pulse rate of 126 beats/min
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance.
Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment.
Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment.
Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success.
In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.