Nokea
Which of the following should be included in the teaching plan for a cancer client who is experiencing thrombocytopenia? Select all that apply.
- A. Use an electric razor.
- B. Use a soft-bristle toothbrush.
- C. Avoid frequent flossing for oral care.
- D. Include an over-the-counter nonsteroidal anti-inflammatory (NSAID) daily for pain control.
- E. Monitor temperature daily.
- F. Report bleeding, such as nosebleed, petechiae, or melena, to a health care professional.
Correct Answer: A,B,C,F
Rationale: Thrombocytopenia increases bleeding risk, so using an electric razor (A), soft-bristle toothbrush (B), avoiding flossing (C), and reporting bleeding (F) are critical to prevent and monitor bleeding complications. NSAIDs (D) are contraindicated, and temperature monitoring (E) is unrelated to thrombocytopenia.
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Ergotamine tartrate (Gynergen) is prescribed for a client's migraine headaches. The client's report of which of the following indicates effectiveness?
- A. Prevention of the migraine.
- B. Reduced severity of the developing migraine.
- C. Relief from the sleeplessness experienced in the past after a migraine.
- D. Relief from the vision problems experienced in the past after a migraine.
Correct Answer: B
Rationale: Ergotamine reduces the severity of developing migraines by constricting cranial blood vessels. It is not primarily preventive or used for post-migraine sleeplessness or vision issues.
The nurse is observing a student nurse administer eyedrops, as shown in the fi gure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client’s eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
Which of the following interventions should the nurse anticipate incorporating into the client's plan of care when hepatic encephalopathy initially develops?
- A. Inserting a nasogastric (NG) tube.
- B. Restricting fluids to 1,000 mL/day.
- C. Administering I.V. salt-poor albumin.
- D. Implementing a low-protein diet.
Correct Answer: D
Rationale: A low-protein diet (D) reduces ammonia production in hepatic encephalopathy. NG tubes (A), fluid restriction (B), and albumin (C) are not primary interventions.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy?
- A. Pains in the joints of the hands and feet.
- B. Tingling in the fingers.
- C. Bleeding on the back of the dressing.
- D. Tension on the suture line.
Correct Answer: B
Rationale: Tetany, caused by hypocalcemia from parathyroid gland damage during thyroidectomy, presents with tingling in the fingers, muscle cramps, or spasms.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan?
- A. Increase daily fluid intake to at least 2 to 3 L.
- B. Strain urine at home regularly.
- C. Eliminate dairy products from the diet.
- D. Follow measures to alkalinize the urine.
Correct Answer: A,B
Rationale: High fluid intake (2-3 L) prevents stone recurrence, and straining urine monitors for stone passage. Dairy restriction or urine alkalinization depends on stone type.