Nokea
Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
- A. Exclude pregnant visitors from the client's room.
- B. Place the client in a negative pressure room.
- C. Have all visitors wear protective masks and boots.
- D. All of the above
Correct Answer: A
Rationale: Brachytherapy involves internal radiation, posing a risk to pregnant individuals due to radiation exposure. Excluding pregnant visitors minimizes this risk.
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A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance?
- A. Increase intake of milk and milk products.
- B. Restrict fluid intake to 1000 mL per day.
- C. Decrease foods high in potassium.
- D. Decrease foods high in sodium.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, so decreasing potassium-rich foods prevents hyperkalemia. Sodium restriction may help edema but is less critical for electrolyte balance in this context.
The nurse is caring for a client with a history of burns. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor urine output.
- B. Administer tetanus prophylaxis.
- C. Provide psychological support.
- D. Restrict visitors to prevent infection.
- E. Apply cold compresses to burns.
Correct Answer: A, B, C
Rationale: Monitoring urine output, tetanus prophylaxis, and psychological support are essential. Visitors should be screened, not restricted, and cold compresses are contraindicated.
A client being discharged from the hospital with a prescription for quinidine to control ventricular ectopy is provided medication instructions by the nurse. Which statement by the client would indicate the need for further teaching?
- A. The best time to schedule this medication is with my meals.
- B. I need to take this medication regularly, even if my heart feels strong.
- C. I should avoid alcohol, caffeine, and cigarettes while on this medication.
- D. If I get diarrhea, nausea, or vomiting, I need to stop the medication immediately.
Correct Answer: D
Rationale: Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine. If these should occur, the primary health care provider or nurse should be notified, but the medication should never be stopped by the client. A rapid decrease in the medication level of an antidysrhythmic could precipitate dysrhythmia. The remaining options are accurate client statements.
The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious anemia?
- A. I will need to increase my dietary intake of foods that are high in vitamin B12.'
- B. I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month.'
- C. I understand that the oral form of vitamin B12 is preferred because it is safer and less expensive than the injection form.'
- D. I will need to take vitamin B12 replacements for the rest of my life.'
Correct Answer: D
Rationale: Pernicious anemia requires lifelong vitamin B12 injections due to intrinsic factor deficiency, preventing absorption of dietary or oral B12.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.