Nokea
A 62-year-old male with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:
- A. Ascites.
- B. Pleural friction rub.
- C. Dyspnea.
- D. Peripheral edema.
Correct Answer: C
Rationale: Dyspnea is a priority assessment for a client with COPD and metastatic lung cancer, as it is a common and distressing symptom requiring palliation in hospice care.
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What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy?
- A. Antibiotics will need to be taken for 1 to 2 weeks.
- B. Arm exercises will get rid of the cellulitis.
- C. Ice pack should be applied to the affected area for 20 minute periods to reduce swelling.
- D. The right extremity should be lowered to improve blood flow to the forearm.
Correct Answer: A
Rationale: Antibiotics for 1-2 weeks are the primary treatment for cellulitis, a bacterial infection, to prevent complications in a post-mastectomy client with lymphedema risk.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
The nurse is caring for a client with suspected retinal detachment. Which of the following manifestations would not be consistent with a diagnosis of retinal detachment?
- A. Seeing 'floaters' in the field of vision
- B. A sense of having a curtain drawn over the eyes
- C. Flashes of light
- D. Intense pain in the affected eye
Correct Answer: D
Rationale: Retinal detachment typically presents with floaters, a curtain-like shadow, and flashes of light due to the retina pulling away from the underlying tissue. Intense pain is not a common symptom, as retinal detachment is usually painless.
A client with breast cancer presents with back pain, weakness, and difficulty urinating. The nurse suspects spinal cord compression. The priority nursing action is to:
- A. Administer analgesics immediately.
- B. Notify the physician for urgent evaluation.
- C. Encourage bed rest in a supine position.
- D. Perform a bladder scan.
Correct Answer: B
Rationale: Spinal cord compression is a medical emergency requiring urgent physician evaluation for imaging and interventions like corticosteroids or surgery to prevent permanent neurologic damage.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Click to highlight the orders that the nurse should consider a priority.
- A. Perform admission medication reconciliation and admit the client to the intensive care unit
- B. Remove the client's clothing
- C. Start a large-bore peripheral vascular access device
- D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once
- E. Obtain medical records from the client's outpatient primary healthcare provider
- F. Insert temperature-sensing indwelling urinary catheter
- G. Apply a cooling blanket to the client
Correct Answer: B,C,D,F,G
Rationale: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.