Nokea
A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
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The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
- A. Place the forearm under a running stream of lukewarm water.
- B. Pat the injury with a dry washcloth.
- C. Wrap the entire forearm from the wrist to the elbow.
- D. Apply an ice pack for 20 minutes.
Correct Answer: C
Rationale: Bufferin (aspirin) impairs platelet function, prolonging bleeding. The first action is to apply pressure by wrapping the forearm to control bleeding. Running water or patting may not provide sufficient pressure, and ice is a secondary measure after bleeding is controlled.
The sense of hearing is assessed using which standardized test?
- A. Taylor test
- B. Rinne test
- C. Babinski test
- D. APGAR test
Correct Answer: B
Rationale: The Rinne test assesses hearing by comparing air and bone conduction using a tuning fork. The Taylor test is not a standard hearing test, the Babinski test evaluates neurological reflexes, and the APGAR test assesses newborn health.
The nurse observes the client instill eyedrops. The client says, 'I just try to hit the middle of my eyeball so the drops don't run out of my eye.' The nurse explains to the client that this method may cause:
- A. Corneal abrasion.
- B. Increased intraocular pressure.
- C. Systemic absorption of the medication.
- D. Ineffective distribution of the medication.
Correct Answer: A
Rationale: Instilling eyedrops directly onto the cornea (middle of the eyeball) can cause corneal abrasion due to the dropper tip or improper technique. Drops should be placed in the lower conjunctival sac.
The nurse is teaching a client about isoniazid (INH). Which of the following statements should the nurse include?
- A. This medication may turn your secretions reddish/orange.
- B. Yellowing of your eyes is a normal side-effect.
- C. A B-complex vitamin should be taken to help with the neuropathy.
- D. This medication will need to be taken every day for at least one week.
Correct Answer: C
Rationale: Isoniazid (INH) can cause peripheral neuropathy, and a B-complex vitamin (especially vitamin B6) is often recommended to help prevent or manage this side effect. Choice A is incorrect because reddish/orange secretions are associated with rifampin, not INH. Choice B is incorrect because yellowing of the eyes (jaundice) is a sign of hepatotoxicity, a serious adverse effect, not a normal side effect. Choice D is incorrect because INH treatment for tuberculosis typically lasts 6-9 months, not just one week.