Nokea
A 36-year-old male with lymphoma is assessing a client who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms?
- A. Flushing, decreased oxygen saturation, mild hypotension.
- B. Low-grade fever, chills, tachycardia.
- C. Elevated temperature, oliguria, hypotension.
- D. High-grade fever, normal blood pressure, increased respirations.
Correct Answer: C
Rationale: Elevated temperature, oliguria, and hypotension are critical signs of septic shock, a life-threatening complication in chemotherapy patients due to neutropenia.
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The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has:
- A. Mild peripheral artery disease
- B. Moderate peripheral artery disease
- C. No apparent occlusion in the left lower extremity
- D. Severe peripheral artery disease
Correct Answer: A
Rationale: ABI = ankle systolic BP ÷ arm systolic BP = 130 ÷ 160 = 0.81. An ABI of 0.8–0.9 indicates mild peripheral artery disease, suggesting some arterial narrowing. Normal ABI is 0.9–1.3, moderate is 0.5–0.8, and severe is <0.5.
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
- A. Administer the medication as a 2-mg bolus.
- B. Give the medication undiluted in incremental doses.
- C. Be alert for shivering and hypotension.
- D. Use only a free-flowing I.V. line in a large vein.
- E. Monitor the client's level of consciousness.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (B), via a free-flowing IV line (D), with monitoring for side effects like shivering and hypotension (C) and level of consciousness (E). A 2-mg bolus (A) is incorrect, as flumazenil is titrated in smaller doses.
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
What is the nurse's priority when a client experiences a seizure?
- A. Restrain the client.
- B. Protect the airway.
- C. Administer oxygen.
- D. Record the duration.
Correct Answer: B
Rationale: Protecting the airway is the priority to ensure oxygenation during a seizure.