Nokea
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer.
Which of the following actions should the nurse take?
- A. Keep visitors at least 6 feet(1.8 m) away from the client.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room.
- C. Wear an isolation gown when caring for the client.
- D. Discard the radioactive source in the client's trash can.
Correct Answer: B
Rationale: The correct answer is B: Place the client's soiled bed linens in a biohazard bag outside the client's room. This is the correct action to prevent the spread of infection, as soiled linens may contain infectious agents. Keeping visitors 6 feet away (choice A) is related to social distancing, not linens handling. Choice C, wearing an isolation gown, is important but not directly related to handling soiled linens. Discarding a radioactive source in the trash can (choice D) is unsafe and violates radiation safety protocols.
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The nurse is caring for a client who is on bed rest.
The nurse should recognize that which of the following findings is a complication of immobility
- A. Increased BP
- B. Urinary frequency
- C. Swollen area on calf
Correct Answer: C
Rationale: The correct answer is C: Swollen area on calf. Immobility can lead to blood pooling in the lower extremities, causing swelling, pain, and potentially leading to deep vein thrombosis (DVT). This is a serious complication that can result from prolonged periods of immobility. Increased blood pressure (choice A) is not typically a direct complication of immobility. Urinary frequency (choice B) is more commonly associated with conditions like urinary tract infections or overactive bladder, not immobility. Swollen area on the calf (choice C) is a hallmark sign of potential DVT in immobile patients.
A nurse is providing discharge teaching to a client following a total gastrectomy.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago.
Which of the following findings indicate a positive test?
- A. An induration measuring 10 mm
- B. A reddened area with no induration
- C. An induration measuring 3 mm
- D. A blister at the injection site
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered positive for a tuberculin skin test, indicating exposure to tuberculosis. A larger induration size suggests a stronger immune response. Choice B, a reddened area with no induration, is not specific for a positive test. Choice C, an induration measuring 3 mm, is below the threshold for positivity. Choice D, a blister at the injection site, is a sign of irritation rather than a positive test result.
A nurse is caring for a client who has an implanted venous access port.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?
- A. Apply a cold compress to the site.
- B. Elevate the affected arm above heart level.
- C. Place a warm, moist compress on the site.
- D. Massage the area to reduce inflammation.
Correct Answer: B
Rationale: The correct answer is B: Elevate the affected arm above heart level. Elevating the affected arm helps reduce swelling and promote circulation, aiding in the healing process. By elevating the arm above heart level, the nurse can assist in reducing inflammation and preventing further complications. Applying a cold compress (choice A) can be helpful for acute injuries, but it may not be the most appropriate initial action. Placing a warm, moist compress (choice C) can potentially worsen swelling in this case. Massaging the area (choice D) could aggravate the injury and increase inflammation.