Nokea
A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now 'unable to concentrate at her card game' and 'it seems harder and harder to finish her errands because of exhaustion.' Based on this information, the nurse should suggest that the client do which of the following?
- A. Take frequent naps.
- B. Limit activities.
- C. Increase fluid intake.
- D. Avoid contact with others.
Correct Answer: A
Rationale: The client's symptoms of difficulty concentrating and exhaustion suggest fatigue, which is a common long-term side effect of chemotherapy. Taking frequent naps can help manage fatigue by allowing the client to rest and conserve energy, improving her ability to perform daily activities. Limiting activities may be overly restrictive and not address the root issue, increasing fluid intake is not directly related to fatigue unless dehydration is present, and avoiding contact with others is unnecessary unless there is an infection risk.
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The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
- A. Pour the solution over ice chips.
- B. Mix the solution with an antacid.
- C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
- D. Disguise the solution in a pureed fruit or vegetable.
Correct Answer: C
Rationale: SSKI has an unpleasant taste and can stain teeth. Diluting it with water, milk, or juice and using a straw minimizes discomfort and staining.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan?
- A. Restrict fluids to 1,000 mL/24 hours.
- B. Drink 400 to 500 mL with each meal.
- C. Drink fluids midmorning, midafternoon, and late afternoon.
- D. Attempt to void at least every 2 hours.
- E. Use intermittent catheterization as needed.
Correct Answer: B,C,D,E
Rationale: Drinking 400-500 mL with meals (B), timing fluids (C), voiding every 2 hours (D), and using intermittent catheterization (E) promote bladder control. Restricting fluids to 1,000 mL/day risks dehydration and is inappropriate.
A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.