Nokea
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
- A. External.
- B. Cyanosis.
- C. Dyspnea.
- D. Weight loss.
Correct Answer: C
Rationale: Dyspnea indicates inadequate oxygenation, suggesting the activity level may be too strenuous for the client's cardiac capacity post-myocardial infarction.
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A client receiving chemotherapy has a platelet count of 15,000 mm³ (15 x 10â¹/L). Based on this laboratory result, which form of precautions should the nurse implement?
- A. Contact
- B. Bleeding
- C. Respiratory
- D. Neutropenic
Correct Answer: B
Rationale: When the platelet count is less than 20,000 mm³ (20 x 10â¹/L), the client is at risk for bleeding, and the nurse should institute bleeding precautions. Contact precautions are initiated in a client who has drainage from wounds that may be infectious. Respiratory precautions are instituted for a client with a respiratory infection that is transmitted by the airborne route. Neutropenic precautions would be instituted for a client with a low neutrophil count.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in his discharge teaching? Select all that apply.
- A. Providing humidity at home.
- B. Following a bland diet.
- C. Learning how to suction himself.
- D. Having communication rehabilitation with a speech pathologist.
- E. Attending a smoking cessation program.
Correct Answer: A,C,D,E
Rationale: After a total laryngectomy, the client needs humidity to keep the airway moist, must learn to suction the airway to maintain patency, requires speech rehabilitation to learn alternative communication methods, and should attend smoking cessation to reduce further risk. A bland diet is not typically required unless specified for other conditions.
The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?
- A. You can drive after being seizure-free for 6 months.
- B. You can drive if you take your medication regularly.
- C. You can drive with a passenger at all times.
- D. You can drive during the daytime only.
Correct Answer: A
Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.
A client states she thinks she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about which of the following?
- A. Menstrual cycle irregularity with increased menstrual flow
- B. Mood swings immediately after menses
- C. Tension and fatigue before menses and through the second day of the menstrual cycle
- D. Midcycle spotting and abdominal pain at the time of ovulation
Correct Answer: C
Rationale: PMS symptoms, such as tension and fatigue, typically occur before menses and may persist into the early menstrual phase. Irregular cycles, post-menses mood swings, or midcycle symptoms are less characteristic of PMS.
A client with a history of type 2 diabetes mellitus is prescribed liraglutide (Victoza). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Liraglutide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.