A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
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Solution
Visitation is limited to 30 minutes when the implant is in place.
Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important.
Options A, B, and C: These statements are not empathetic and do not address the question; therefore, they are incorrect.
The best method of evaluating the amount of peripheral edema is:
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Solution
Measuring the extremity
The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment.
Option A: Weighing the client will not indicate peripheral edema.
Option C: Measuring the intake and output will not indicate peripheral edema.
Option D: Checking for pitting edema is less reliable than measuring with a paper tape measure.
The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
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Solution
Administer the medications
Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension.
Options A, C, and D: The order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
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Solution
Phlebostatic axis
The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer.
Option B: The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line.
Option C: Erb’s point is the point at which you can hear the valves close simultaneously.
Option D: The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with the placement of a manometer.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
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Solution
Neck
The jugular veins in the neck should be assessed for distension.
Options A, C, and D: The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
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Solution
Turkey breast
Turkey contains the least amount of fats and cholesterol.
Options A, B, and D: Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.
The client admitted with angina is given a prescription for nitroglycerin. The client should be instructed to:
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Solution
Leave the medication in the brown bottle
Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water.
Options A and B: The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides. If the pain does not subside, the client should report to the emergency room.
Option D: The medication should be taken sublingually and should not be crushed.
The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
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Solution
Heart rate of 60 bpm
A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100 bpm.
Options A, B, and D: The blood glucose, blood pressure, and respirations are within normal limits.
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
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Solution
Check the blood glucose level
Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped.
Option A: Diazoxide (Hyperstat) is given by IV push.
Option C: The client should be placed in dorsal recumbent position, not a Trendelenburg position.
Option D: This medication does not have to be covered with foil.
The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
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Solution
Report muscle weakness to the physician.
The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis.
Option B: The medication takes effect within 1 month of beginning therapy.
Option C: The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness.
Option D: Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.