Nokea
A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?
- A. Malignancy
- B. Infection
- C. Benign cyst
- D. Lymphadenitis
Correct Answer: A
Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.
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A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?
- A. White blood cell count of 2,000/mm³
- B. Platelet count of 100,000/mm³
- C. Hemoglobin level of 10 g/dL
- D. Serum creatinine level of 1.5 mg/dL
Correct Answer: A
Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.
A client with rheumatoid arthritis is prescribed methotrexate. Which laboratory value should the nurse monitor closely?
- A. White blood cell count of 10,000/mm³
- B. Hemoglobin of 12 g/dL
- C. Liver function tests
- D. Platelet count of 150,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Liver function tests. Methotrexate can cause hepatotoxicity, making it essential to closely monitor liver function tests in clients receiving this medication. Monitoring white blood cell count, hemoglobin, or platelet count is not specifically required for methotrexate therapy and would not provide relevant information regarding potential adverse effects of the medication.
A client with a history of chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. White blood cell count
- C. Hemoglobin level
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. In a client receiving erythropoietin therapy for chronic kidney disease, monitoring serum potassium levels is crucial due to the risk of hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increased demand for potassium. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because erythropoietin therapy specifically impacts potassium levels, not white blood cell count, hemoglobin level, or serum calcium level.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding is most concerning to the nurse?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Respiratory rate of 28 breaths per minute
Correct Answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and indicates hypoxemia, requiring immediate intervention. In COPD, the body's ability to oxygenate adequately is already compromised, so a saturation of 85% is particularly concerning. A barrel-shaped chest and use of accessory muscles are common findings in COPD due to chronic air trapping and increased work of breathing. While a respiratory rate of 28 breaths per minute is elevated, a low oxygen saturation is a more critical finding that necessitates prompt attention.
A client is being treated with an aminoglycoside antibiotic for a serious gram-negative infection. What nursing action should be included in the plan of care to prevent nephrotoxicity?
- A. Monitor serum creatinine levels daily.
- B. Administer the antibiotic over a longer period of time.
- C. Encourage increased fluid intake.
- D. Restrict dietary protein intake.
Correct Answer: A
Rationale: Monitoring serum creatinine levels daily is the essential nursing action to prevent nephrotoxicity from aminoglycoside antibiotics. Aminoglycosides can cause kidney damage, so monitoring serum creatinine levels helps in detecting early signs of nephrotoxicity. Administering the antibiotic over a longer period of time (choice B) does not directly prevent nephrotoxicity. Encouraging increased fluid intake (choice C) is a general good practice but not specifically aimed at preventing nephrotoxicity. Restricting dietary protein intake (choice D) is not a direct preventive measure against aminoglycoside-induced nephrotoxicity.