NCLEX-PN

Correct Response : C Explanation : Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm, with the exception of the number of beats per minute. Sinus bradycardia has a cardiac rate less than 60 beats per minute, the atrial and ventricular rhythms are regular, the P wave occurs prior to each and every QRS complex, the P waves are uniform in shape, the length of the PR interval is from 0.12 to 0.20 seconds, the QRS complexes are uniform, and the length of these QRS complexes is from 0.06 to 0.12 seconds. (See Sinus Rhythms ) 8. Your client is receiving phototherapy. What nursing intervention would you implement for this client? A.​ Placing the client in the Trendelenburg position Correct Response : B Explanation : You would monitor the color of the stools for the client who is receiving phototherapy. Phototherapy is used to treat psoriasis, but it is most commonly employed for the treatment of neonatal hyperbilirubinemia and jaundice, which can occur among both full term and preterm infants. You would also monitor and document the client’s: Skin for changes in color that may indicate an increase or decrease in the amount of bilirubin in the client’s blood Laboratory bilirubin levels to determine whether or not the client’s bilirubin levels are decreasing as a result of the phototherapy. Volume, color and characteristics of the stool because phototherapy can lead to frequent, loose stools as well as a color change to green colored stools. (See Implementing and Monitoring Phototherapy ) 9. Which of the following is an adverse effect of radiation therapy? B.​ Monitoring the color of the stools C.​ Using a Hoyer lift for client transfers D.​ Monitoring the arterial blood gases

A.​ Fibrosis B.​ Alopecia

C.​ Oral dryness D.​ Xerostomia Correct Response : A

Explanation : Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart, in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue. Alopecia and oral dryness, also referred to as xerostomia, are side effects and complications to radiation, but not adverse effects.

Other side effects, complications, and adverse effects associated with therapeutic radiation therapy are:

●​ Skin damage ●​ Damage to the mucosa

●​ Dental caries and oral infections ●​ Fatigue

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