Nokea
Which of the following client situations would require the most intensive nursing interventions for immobility?
- A. A 38-year-old woman receiving internal radiation therapy for cervical cancer.
- B. A 7-year-old boy with leukemia hospitalized for induction of high-dose chemotherapy.
- C. A 75-year-old man with metastatic prostate cancer hospitalized for a pathologic fracture of the femur.
- D. A 6-month-old undergoing surgery for placement of a central venous catheter.
Correct Answer: C
Rationale: A 75-year-old man with a pathologic femur fracture requires the most intensive nursing interventions for immobility due to pain, risk of further injury, and need for mobility aids and rehabilitation.
You may also like to solve these questions
The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as
- A. a vesicant drug entering into intradermal tissue.
- B. a non-vesicant drug entering subcutaneous tissue.
- C. a vesicant drug entering into subcutaneous tissue.
- D. a vesicant drug entering the muscle by injection.
Correct Answer: B
Rationale: Infiltration involves non-vesicant fluid leaking into subcutaneous tissue, causing swelling and discomfort.
A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?
- A. Deep, rapid respirations with long expirations.
- B. Shallow respirations alternating with long expirations.
- C. Regular depth of respirations with frequent pauses.
- D. Short expirations and inspirations.
Correct Answer: A
Rationale: Deep, rapid respirations (Kussmaul respirations) indicate diabetic ketoacidosis, a life-threatening condition requiring immediate intervention.
The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?
- A. Emboli formation.
- B. Fluid volume overload.
- C. Red blood cell hemolysis.
- D. Allergic reaction.
Correct Answer: B
Rationale: A slow infusion rate (60 mL/hour) prevents fluid volume overload, especially in clients at risk post-trauma. Emboli, hemolysis, and allergic reactions are less directly related to infusion rate.
The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations?
- A. Completing the spring semester of school.
- B. Gaining 4 pounds.
- C. Becoming engaged.
- D. Undergoing a root canal.
Correct Answer: D
Rationale: Stressful situations like surgery or dental procedures (e.g., root canal) increase glucocorticoid needs in Addison's disease to prevent adrenal crisis.
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
- A. Use a heating pad under the right arm.
- B. Place ice on the area after each treatment.
- C. Apply deodorant only under the left arm.
- D. Use a soft washcloth to gently cleanse the area.
Correct Answer: C
Rationale: Applying deodorant only under the left arm avoids irritation to the radiated right axilla, which is sensitive and prone to skin reactions during treatment.