Nokea
A client with internal radiation.
Which of the following actions, if taken by the nurse, is MOST important?
- A. Restrict visitors who may have an upper respiratory infection.
- B. Assign only male caregivers to the client.
- C. Plan nursing activities to decrease nurse exposure.
- D. Wear a lead-lined apron whenever delivering client care.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
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The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?
- A. Change in the character of respirations.
- B. Fluctuation in the blood pressure.
- C. Reduction in tissue turgor.
- D. Increase in body temperature.
Correct Answer: A
Rationale: will see dyspnea, cough, edema, hemoptysis
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color