Nokea
A client diagnosed with multiple myeloma is receiving intravenous hydration at 100 mL per hour. Which finding indicates to the nurse that the client is experiencing a positive response to the treatment plan?
- A. Weight increase of 1 kilogram
- B. Respirations of 18 breaths per minute
- C. Creatinine of 1.0 mg/dL (88 mcmol/L)
- D. White blood cell count of 6000 mm3 (6 × 109/L)
Correct Answer: C
Rationale: Multiple myeloma is a malignant proliferation of plasma cells within the bone. Renal failure is a concern in the client with multiple myeloma. In multiple myeloma, hydration is essential to prevent renal damage resulting from precipitation of protein in the renal tubules and excessive calcium and uric acid in the blood. Creatinine is the most accurate measure of renal function. Options 2 and 4 are unrelated to the subject of hydration. Weight gain is not a positive sign when concerned with renal status.
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The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client's beliefs?
- A. Is accepting of body size
- B. Views purging as an accepted behavior
- C. Overeats for the enjoyment of eating food
- D. Overeats in response to losing control of diet
Correct Answer: B
Rationale: Individuals with bulimia nervosa develop cycles of binge eating, followed by purging. They seldom attempt to diet and have no sense of loss of control. Options 1, 3, and 4 are true of the obese person who may binge eat (not purge).
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply.
- A. Dyspnea
- B. Flat neck veins
- C. Nausea and vomiting
- D. Chest pain or discomfort
- E. Hypotension and dizziness
- F. Hypertension and headache
Correct Answer: A,D,E
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are associated with the effects of uncontrolled atrial fibrillation.
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions should the nurse include in the plan? Select all that apply.
- A. Avoid heavy lifting.
- B. Sit as much as possible.
- C. Take baths rather than showers.
- D. Limit stair climbing to five times a day.
- E. Gradually increase walking as exercise but stop before becoming fatigued.
- F. Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.
Correct Answer: A,D,E,F
Rationale: After abdominal hysterectomy, the client should avoid lifting anything that is heavy and limit stair climbing to five times a day. The client should walk indoors for the first week and then gradually increase walking as exercise, but stop before becoming fatigued. The client should avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks. The client is also told to avoid the sitting position for extended periods, to take showers rather than tub baths, avoid crossing the legs at the knees, and avoid driving for at least 4 weeks or until the surgeon has given permission to do so.
The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
- A. Rinsing it in sterile water
- B. Suctioning the client's airway
- C. Tapping it gently against a sterile basin
- D. Drying it with the provided pipe cleaners
Correct Answer: D
Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant.
In preparation to administer an intermittent tube feeding, the nurse aspirates 40 mL of undigested formula from the client's nasogastric tube. Which intervention should the nurse implement as a result of this finding?
- A. Discard the aspirate and record as client output.
- B. Mix with new formula to administer the feeding.
- C. Dilute with water and inject into the nasogastric tube.
- D. Reinstill the aspirate through the nasogastric tube via gravity and syringe.
Correct Answer: D
Rationale: After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) to maintain the client's fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can also disrupt the client's fluid and electrolyte balance unless the client is dehydrated.