Nokea
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
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Select the electrolyte that is accurately paired with its normal level.
- A. Phosphate: From 0.81 to 1.45 mmol/L.
- B. Chloride: From 60 to 110 mEq/L.
- C. Calcium: From 6.5 - 10.6 mg/dL.
- D. Potassium: From 3.7 to 7.2 mEq/L.
Correct Answer: A
Rationale: Normal phosphate levels are 0.81 to 1.45 mmol/L (2.5 to 4.5 mg/dL), making this the correct pairing.
The nurse should give which medication instructions to the client prescribed quinapril hydrochloride?
- A. Take the medication with food only.
- B. Expect a therapeutic effect immediately.
- C. Discontinue the medication if nausea occurs.
- D. Rise slowly from a lying to a sitting position.
Correct Answer: D
Rationale: Quinapril hydrochloride is an angiotensin-converting enzyme (ACE) inhibitor. It is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. A full therapeutic effect may be noted in 1 to 2 weeks. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast.
The nurse is caring for a client taking memantine. Which data should the nurse monitor for this client?
- A. Liver function studies
- B. Complete blood count
- C. Renal function studies
- D. Pulmonary function studies
Correct Answer: C
Rationale: Memantine is a medication used to treat moderate to severe Alzheimer's disease. This medication needs to be avoided in clients with severe renal dysfunction, and a reduced dosage is needed in moderate renal dysfunction. The other options are not specifically associated with this medication.
Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client?
- A. Administer oxygen therapy as needed to maintain adequate oxygenation.
- B. Offer pain medication before having the client deep-breathe and use incentive spirometry.
- C. Encourage the client to cough, deep-breathe, and turn in bed and to 2,000 mL every 24 hours.
- D. Encourage the client to cough, deep-breathe, and turn in bed every 2 hours.
Correct Answer: B
Rationale: Pain control is essential to enable effective deep breathing and incentive spirometry, which prevent atelectasis and pneumonia by promoting lung expansion. Oxygen and fluid intake are supportive but secondary.
A nurse is having difficulty establishing a relationship with an aggressive client. What strategy will most likely improve the relationship?
- A. The nurse and the client agree to work to improve their involvement in the therapeutic relationship.
- B. The nurse establishes goals for having only positive interactions with the client.
- C. The nurse agrees to be submissive so the client can dominate the relationship.
- D. The nurse seeks assistance from colleagues to become more aware of the quality of the interactions and more sensitive to the dynamics of communication.
Correct Answer: D
Rationale: Seeking colleague assistance enhances self-awareness and communication skills, improving the therapeutic relationship with an aggressive client.