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A 17-year-old client has been admitted to the hospital for a biopsy to confirm the diagnosis of bone cancer. The nurse should assess the client for which conditions? Select all that apply.
- A. Cough.
- B. Dyspnea.
- C. Pain.
- D. Swelling.
- E. Fever.
- F. Anorexia.
- G. Decreased range of motion.
Correct Answer: C,D,E,F,G
Rationale: Bone cancer may cause pain, swelling, fever, anorexia, and decreased range of motion due to tumor effects on bone and surrounding tissues. Cough and dyspnea are less common unless metastasis occurs.
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A client with a history of depression is prescribed duloxetine (Cymbalta). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Duloxetine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
A client with a history of type 2 diabetes is prescribed insulin glargine (Lantus). The nurse should instruct the client to:
- A. Take the insulin at bedtime.
- B. Mix the insulin with short-acting insulin.
- C. Take the insulin with meals.
- D. Stop the insulin if blood glucose normalizes.
Correct Answer: A
Rationale: Insulin glargine, a long-acting insulin, is typically taken at bedtime for basal coverage.
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
- A. Encourage the client to cough and deep breathe.
- B. Add water to the suction chamber as it evaporates.
- C. Keep the collection chamber below the client's waist.
- D. Clamp the chest tube when the client gets out of bed.
- E. Tape the connection between the chest tube and the drainage system.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection. To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.
- A. Maintain the client in a position of comfort.
- B. Collect sputum specimens at the hour of sleep.
- C. Offer medication to suppress the cough as needed.
- D. Administer small, frequent meals with plenty of fluids.
- E. Have the client cough and breathe deeply 20 minutes after pain medication is given.
- F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.
Correct Answer: A,D,E
Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.
You have been conducting a weekly outpatient stress management educational series for clients in the community who are hypertensive. The best way to evaluate the effectiveness of this educational series is to:
- A. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.
- B. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data after the series is completed.
- C. Ask the clients how often they use the stress management techniques that they have learned during this educational series.
- D. Use a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series.
Correct Answer: A
Rationale: Collecting and comparing blood pressure data before, during, and after the series provides objective evidence of the program's effectiveness in managing hypertension.