If a Wall unit is used, What should be the suctioning pressure required by James?

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.

Correct Answer: B

Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5 FU [Fluoroplex]). Fluorouracil is commonly used in chemotherapy for liver cancer to inhibit cancer cell growth. It is a pyrimidine analog that interferes with DNA synthesis. Fluoxymesterone (A) is an androgen used in hormone replacement therapy, not in liver cancer treatment. Tamoxifen (C) is an antiestrogen used in breast cancer treatment, not liver cancer. Megestrol (D) is a progestin used in hormone therapy for breast cancer and endometrial cancer, not liver cancer. Therefore, the correct choice is B as it directly targets cancer cell growth in liver cancer treatment.

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.

Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.

Correct Answer: B

Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.

Correct Answer: B

Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection. Summary: A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure. C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention. D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.

Correct Answer: C

Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather data from the patient's body, such as vital signs, appearance, and overall health status. It provides essential information to establish a patient's database, including baseline values and potential health issues. Reviewing current literature (A) helps in decision-making but does not directly establish a patient's database. Checking orders for tests (B) and ordering medications (D) are part of the treatment process and do not focus on gathering initial patient data.