Nokea
A client with a diagnosis of breast cancer is prescribed anastrozole (Arimidex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of anastrozole requiring immediate reporting.
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An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply.
- A. Friends can visit whenever they want.
- B. The scar will be small.
- C. The teen will be back in school in 1 week.
- D. Antibiotics will be given to prevent an infection.
- E. A dressing will stay in place for 1 week.
Correct Answer: B,C,D
Rationale: A small scar, school return in about a week, and prophylactic antibiotics are accurate expectations for appendectomy recovery. Unrestricted visits and prolonged dressing use are incorrect.
A client with a history of myocardial infarction is prescribed aspirin. The nurse should explain that the primary purpose of this medication is to:
- A. Reduce chest pain.
- B. Prevent platelet aggregation.
- C. Lower blood pressure.
- D. Decrease heart rate.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of further clot formation in clients with a history of myocardial infarction.
The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious anemia?
- A. I will need to increase my dietary intake of foods that are high in vitamin B12.'
- B. I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month.'
- C. I understand that the oral form of vitamin B12 is preferred because it is safer and less expensive than the injection form.'
- D. I will need to take vitamin B12 replacements for the rest of my life.'
Correct Answer: D
Rationale: Pernicious anemia requires lifelong vitamin B12 injections due to intrinsic factor deficiency, preventing absorption of dietary or oral B12.
Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been unresponsive to other antipsychotics. The client states, 'Why do I have to have a blood test every week?' Which of the following responses by the nurse would be most appropriate?
- A. Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the medication on the blood.'
- B. Weekly blood tests are done so that you can receive another week's supply of the medication.'
- C. Your physician will want to know how well you are personally progressing with the medication therapy.'
- D. Everyone who takes this drug must go through the same procedure because it is required by the drug company.'
Correct Answer: A
Rationale: Weekly blood tests monitor for agranulocytosis, a serious side effect of clozapine, ensuring safe dosing and early detection of blood abnormalities.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.