Nokea
A 52-year-old client with lung cancer tells the nurse that he has a low-grade fever (100.6°F [38.1°C]), nonproductive cough, and increasing fatigue. He completed the radiation therapy to the mass in his right lung and mediastinum 10 weeks ago and has a follow-up appointment to see the physician in 2 weeks. What is the most appropriate response by the nurse?
- A. Advise the client to take two acetaminophen tablets every 4 to 6 hours for 2 days and call back if his temperature increases to 101°F (38.3°C) or greater.
- B. Advise the client that this is an expected side effect of the radiation therapy and to keep his appointment in 2 weeks.
- C. Advise the client to come to the office to be examined today.
- D. Advise the client to go to the nearest emergency department.
Correct Answer: C
Rationale: Fever, cough, and fatigue post-radiation may indicate infection or pneumonitis, requiring prompt evaluation, especially in a lung cancer patient, so an office visit today is appropriate.
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During the assessment of a client's mouth, the nurse notes the absence of saliva. The client has pain in the area of the ear. The client has been nothing-by-mouth (NPO) for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions?
- A. Stomatitis.
- B. Oral candidiasis.
- C. Parotitis.
- D. Gingivitis.
Correct Answer: C
Rationale: Parotitis, inflammation of the parotid gland, is suggested by the absence of saliva and ear pain, especially in a client who is NPO and dehydrated, which can impair salivary gland function. Stomatitis, oral candidiasis, and gingivitis typically present with different symptoms, such as mucosal inflammation, white patches, or gum bleeding.
The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next?
- A. Auscultate the pulses with a stethoscope
- B. Call the physician
- C. Use a Doppler ultrasound device
- D. Inspect the lower left extremity
Correct Answer: C
Rationale: If pedal pulses are not palpable, the next step is to use a Doppler ultrasound device to detect blood flow, as pulses may be weak due to PVD or other causes. Auscultation is not used for peripheral pulses, calling the physician is premature, and inspection is less specific than Doppler assessment.
The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
- A. Peritonitis.
- B. Thrombophlebitis.
- C. Ingestes.
- D. Inguinal hernia.
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.
The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)?
- A. Antihypertensives.
- B. Anticoagulants.
- C. Alcohol.
- D. Cimetidine.
Correct Answer: C
Rationale: Alcohol can enhance the sedative effects of metoclopramide and worsen gastrointestinal symptoms, so it should be avoided.