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A 56-year-old female client is receiving intracavitary radiation via a
radium implant. Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary
radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium
difficile. -
correct answer ✅B. A nurse with Marfan's syndrome who is
postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as
long as the intracavity
radiation source is in place. A nurse's ability to care of this client is
not affected by Marfan's
syndrome (B), which is a hereditary disorder of connective tissues,
bones, muscles, ligaments
and skeletal structures. The goal is to limit any one staff member's
exposure to the calculated
time span based on the half-life of radium, such as the number of
minutes at the bedside per day,
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so (A) should not be assigned. (C) should not be exposed to the
radiation due to the possible
effect on the fetus. A radiation exposure decreases the immune
response in the client who should
not be exposed to the potential inadvertent transmission of an
infectious organism (D).
1.A client who has active tuberculosis (TB) is admitted to the
medical unit. What action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway -
correct answer ✅Assign the client to a negative air-flow room
RATIONALE:
Active tuberculosis requires implementation of airborne
precautions, so the client should be
assigned to a negative pressure air-flow room (D). Although (A and
C) should be implemented
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for clients in isolation with contact precautions, it is most important
that air flow from the room
is minimized when the client has TB. (B) should be implemented
when the client leaves the
isolation environment.
2.A client is receiving atenolol (Tenormin) 25 mg PO after a
myocardial infarction. The nurse
determines the client's apical pulse is 65 beats per minute. What
action should the nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. -
correct answer ✅Administer the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial
node to reduce the heart rate,
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so the medication should be administered (C) because the client's
apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the
thyroid. This finding is consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism -
correct answer ✅Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid
gland, often referred to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in
glandular vascularity which
increases as the thyroid gland becomes hyperactive. A bruit is not
common with (A, B, and C).
A 6-year-old child is alert but quiet when brought to the emergency
center with periorbital ecchymosis and ecchymosis behind the ears.