Nokea
A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?
- A. Oxygen at 4 L per nasal cannula.
- B. Potassium 40 mEq PO now.
- C. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour.
- D. NaHCO‚ƒ 75 mEq IV.
Correct Answer: C
Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.
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In developing a teaching plan for the client with a hiatal hernia, the nurse's assessment of which work-related factors would be most useful?
- A. Number and length of breaks.
- B. Body mechanics used in lifting.
- C. Temperature in the work area.
- D. Cleaning solvents used.
Correct Answer: B
Rationale: Poor body mechanics during lifting can increase intra-abdominal pressure, exacerbating hiatal hernia symptoms, making this the most relevant work-related factor.
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
- A. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet
- B. Decreasing the pain by producing analgesia
- C. Increasing the blood supply to the affected area
- D. Increasing monoamine oxidase
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate?
- A. Maintaining an upright position.
- B. Restricting the diet to liquids until swallowing improves.
- C. Introducing foods on the unaffected side of the mouth.
- D. Keeping distractions to a minimum.
Correct Answer: B
Rationale: Restricting the diet to liquids increases aspiration risk, as liquids are harder to control. Upright positioning, using the unaffected side, and minimizing distractions reduce aspiration risk.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or dehydration, requiring urgent attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical symptoms.
A client with bladder cancer receives intravesical chemotherapy. The nurse should:
- A. Monitor for hematuria.
- B. Restrict fluids.
- C. Administer pain medication.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Hematuria is a potential side effect of intravesical chemotherapy, requiring monitoring.