Nokea
While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
- A. Place the implant in a biohazard bag and return it to the lab
- B. Give the client a pair of gloves and ask her to reinsert the implant
- C. Use tongs to pick up the implant and return it to a lead-lined container
- D. Discard the implant in the commode and double-flush
Correct Answer: C
Rationale: Radioactive implants must be handled with tongs and placed in a lead-lined container to minimize radiation exposure, per safety protocols.
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A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?
- A. My sister still has episodes of crying, and it's been three months since Daddy died.
- B. Sally seems to have forgotten the bad things that Daddy did in his lifetime.
- C. She really had a hard time after Daddy's funeral. She said that she had a sense of longing.
- D. She has not been saddened at all by Daddy's death. She acts like nothing has happened.
Correct Answer: D
Rationale: Denial of grief, as indicated by acting like nothing has happened, suggests abnormal grieving, as it may reflect an inability to process the loss.
A client is to receive 1,000 mL of potassium chloride in 5% dextrose injection (D5W) intravenously over 3 hours and 20 minutes using a drop factor of 15 drops/mL. What is the required flow rate (drops) per minute? Record your answer using a whole number.
Correct Answer: 75
Rationale: To calculate the flow rate in drops per minute, use the formula: (Total volume X Drop factor)/ Total time in minutes. The total volume is 1,000 mL, the drop factor is 15 drops/mL, and the time is 3 hours 20 minutes = 200 minutes. Thus, (1,000 X 15)/ 200 = 15,000/ 200 = 75 drops/minute.
Arterial ulcers are best described as ulcers that:
- A. Are smooth in texture
- B. Have irregular borders
- C. Are cool to touch
- D. Are painful to touch
Correct Answer: D
Rationale: Arterial ulcers are typically painful due to poor blood flow and tissue ischemia.
The nurse has rounded on all the assigned clients. While rounding, several health care providers have written orders on the nurse's clients. Which order would be the priority for the nurse to address?
- A. furosemide (Lasix) 80 mg IV push STAT for a client with fluid overload
- B. a new insulin sliding scale for a client with a glucose level of 242
- C. perform a dressing change on a client with a stage 2 diabetic foot ulcer
- D. discharge a client who was admitted for removal of an abdominal abscess
Correct Answer: A
Rationale: STAT orders for furosemide address acute fluid overload, a potentially life-threatening condition, making it the priority over insulin, dressing changes, or discharge.
The nurse is teaching a female client who is experiencing urge incontinence how to manage her condition at home. Which statement by the client indicates a need for further explanation by the nurse?
- A. I will be cured in four weeks if I follow the bladder retraining instructions.
- B. I will perform the pelvic muscle exercises daily.
- C. I will wait five minutes once I get the urge to urinate to go to the bathroom.
- D. I will empty my bladder when I first get up in the morning.
Correct Answer: A
Rationale: Urge incontinence may not be cured in four weeks; bladder retraining aims to manage symptoms, not guarantee a cure, indicating a need for further teaching.