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A. A client has an indwelling urinary catheter, and urine is leaking from a hole in the collection bag. Which of the following nursing interventions would be most appropriate?
1. Cover the hole with tape.
2. Remove the catheter and insert a new one using sterile technique.
3. Disconnect the drainage bag from the catheter and replace it with a new bag.
4. Place a towel under the bag to prevent spillage of urine on the floor, which could cause the client to slip and fall.
B. During a routine physical examination, a firm mass is palpated in the right breast of a 35 year old woman. Which of the following findings or client history would suggest cancer of the breast as opposed fibrocystic disease?
1. History of early menarche
2. Cyclic change in mass or size
3. History of anovulatory cycles
4. Increased vascularity of the breast
C. Two days after a transrectal biopsy of the prostate, a client calls the clinic to report his stool is streaked with blood. Which of the following responses is appropriate?
1. Tell the client to take a laxative.
2. Tell the client to come in for examination.
3. Reassure the client this is an expected occurrence.
4. Ask the client to collect a stool specimen for testing.
D. Which of the following statements is correct about the rate of cell growth in relation to chemotherapy?
1. Faster growing cells are less susceptible to chemotherapy.
2. Nondividing cells are more susceptible to chemotherapy.
3. Faster growing cells are more susceptible to chemotherapy.
4. Slower growing cells are more susceptible to chemotherapy.
E. Which of the following foods should a client with leukemia avoid?
1. White bread.
2. Carrot sticks.
3. Stewed apples.
4. Medium rare steak
F. A client with anemia may be tired due to a tissue deficiency of which of the following substances.
1. Carbon dioxide
2. Factor VIII
3. Oxygen
4. T-cell antibodies
G. A middle-aged client client arrives at the emergency department complaining of chest and stomach pain. He also reports passing black stools for a month. Which of the following interventions is done first?
1. Give nasal oxygen.
2. Take his vital signs.
3. Begin cardiac monitoring.
4. Draw blood for laboratory analysis.
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3 comments:
These questions came from NCLEX-RN Questions & Answers made Incredibly Easy
A-2 The system is no longer a closed system, and bacteria might have been introduced into the system, so a new sterile catheter shuld be inserted.
B-4 Increase in breast size or vascularity is consistent with cancer of the breast.
C-3 After a transrectal prostatic biopsy, blood in the stool is expected for a number of days.
D-3 The faster the cell grows, the more susceptible it is to chemotherapy and radiation therapy.
E-2 A low-bacteria diet would be indicated, which excludes raw fruits and vegetables.
F-3 Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen in body tissues.
G-2 His vital signs will show hemodynamic stability, and monitoring his heart rhythm may be indicated based on your findings.
If you want to know the rationale on any of the other choices, let me know.
Hi Bonnie,
Can you please post the rationale for A and E. Thanks.
Rationale for wrong choices of A & E.
A. Placing a towel under the bag and taping up the hole leaves the system open, which increases the risk of infection. Replacing the drainage bag by disconnecting the old one from the catheter opens up the entire system and isn't recommended due to the increased risk of infection.
E. The other choices offered, have all had heat applied which kills bacteria. Shelba also talked about canned food as being safe and sterile. Boiling apples, baking bread, and cooking meat to a high enough temp should kill off harmful stuff.
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