Nokea
What should be included in Mr. Ross’s plan of care during radiation therapy if he complains of weakness and lethargy?
- A. Encouraging him to rest more than usual
- B. Monitoring his intake and output
- C. Helping him to accept his condition
- D. Checking his blood pressure daily
Correct Answer: A
Rationale: Rest conserves energy and aids recovery during radiation therapy.
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You are caring for a patient who has had a transurethral resection of the prostate for benign prostatic hypertrophy. There is continuous bladder irrigation setup. You would notify the physician if you noted
- A. Any signs of hematuria.
- B. A change from clear red output to thicker, bright red output.
- C. A decrease in the amount of blood in the urine.
- D. The development of uremic pruritis.
Correct Answer: B
Rationale: Thicker, bright red output indicates potential bleeding requiring medical attention.
Why may it pose a challenge to supplement or restrict dietary consumption when providing health-related education to clients from culturally diverse populations?
- A. Cultural beliefs about food may conflict with dietary recommendations.
- B. Clients may prefer traditional healers over modern medicine.
- C. Language barriers may hinder understanding.
- D. All of the above.
Correct Answer: A
Rationale: Cultural beliefs significantly influence dietary habits, requiring sensitivity and adaptation in health education.
When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced.
A: Using aseptic technique is important but not the immediate priority in this situation.
B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change.
D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.
Which of the following would have the highest priority in septic shock?
- A. Monitoring temperature.
- B. Monitoring pupillary reaction.
- C. Monitoring airway, breathing, circulation (ABC).
- D. Monitoring ANA and RF levels.
Correct Answer: C
Rationale: Maintaining ABCs is critical in septic shock.
What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.