Nokea
Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.
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A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
- A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
- B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
- C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
- D. I can see that you are upset. Would you like to share your concerns with me?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.
A client is receiving an I.V. infusion of 5% dextrose in water (D5W). The skin around the I.V. insertion site is red, warm to touch, and painful. The nurse should first:
- A. Administer acetaminophen (Tylenol)
- B. Change the D5W to normal saline
- C. Discontinue the I.V.
- D. Place a warm compress on the area
Correct Answer: C
Rationale: Redness, warmth, and pain at the I.V. site indicate phlebitis or infiltration. The first action is to discontinue the I.V. to prevent further tissue damage. Changing fluids, applying a compress, or giving acetaminophen does not address the immediate issue.
The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis?
- A. Take the medication with antacids.
- B. Double the dosage if a drug dose is missed.
- C. Increase intake of dairy products.
- D. Limit alcohol intake.
Correct Answer: D
Rationale: Limiting alcohol intake prevents hepatotoxicity, a risk with isoniazid and rifampin. Antacids may reduce absorption. Doubling doses is dangerous. Dairy intake is unrelated.
Which of the following areas is a priority to evaluate when completing discharge planning for a client who has had a lobectomy for treatment of lung cancer?
- A. The support available to assist the client at home.
- B. The distance the client lives from the hospital.
- C. The client's ability to do home blood pressure monitoring.
- D. The client's knowledge of the causes of lung cancer.
Correct Answer: A
Rationale: Home support is critical post-lobectomy to assist with recovery, medication adherence, and monitoring complications. Distance from the hospital, blood pressure monitoring, and knowledge of cancer causes are less immediate priorities.