Nokea
A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:
- A. Hiatal hernia.
- B. Stomatitis.
- C. Radiation enteritis.
- D. Esophagitis.
Correct Answer: D
Rationale: Pain while swallowing and chest burning/tightness suggest esophagitis, a common side effect of chest wall radiation due to irritation of the esophageal mucosa.
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The most common issue associated with sleep disturbances in the hospitalized client with cancer is:
- A. Social.
- B. Nutritional.
- C. Cultural.
- D. Psychological.
Correct Answer: D
Rationale: Psychological factors, such as anxiety or fear related to cancer diagnosis and treatment, are the most common causes of sleep disturbances in hospitalized cancer patients.
If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
- A. Oliguria.
- B. Bradycardia.
- C. Elevated blood pressure.
- D. Fever.
Correct Answer: A
Rationale: Cardiogenic shock causes decreased cardiac output, leading to reduced renal perfusion and oliguria (low urine output). Bradycardia, elevated BP, and fever are not typical signs.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
A nurse is preparing to administer furosemide intravenously to a client. Which action should the nurse perform before administering this medication?
- A. Insert an indwelling urinary catheter.
- B. Review the client's most recent pulse
- C. Establish continuous pulse oximeter monitoring
- D. Assess the client's serum electrolytes
Correct Answer: D
Rationale: Furosemide can cause electrolyte imbalances, so assessing serum electrolytes is critical before administration.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.