Nokea
A client with a history of breast cancer is prescribed tamoxifen (Nolvadex). Which side effect should the nurse teach the client to report?
- A. Hot flashes
- B. Weight gain
- C. Vaginal bleeding
- D. Fatigue
Correct Answer: C
Rationale: Vaginal bleeding may indicate endometrial hyperplasia or cancer, a serious side effect of tamoxifen requiring immediate reporting.
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A client with a history of tuberculosis is prescribed isoniazid (INH). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Isoniazid can cause hepatotoxicity, requiring regular liver function monitoring.
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
A client with a history of heart failure is admitted with worsening symptoms. The nurse should monitor the client for which of the following laboratory abnormalities? Select all that apply.
- A. Hyponatremia.
- B. Hyperkalemia.
- C. Elevated B-type natriuretic peptide (BNP).
- D. Hypomagnesemia.
- E. Elevated creatinine.
Correct Answer: A, C, E
Rationale: Heart failure can cause hyponatremia (fluid overload), elevated BNP (cardiac stress), and elevated creatinine (renal impairment).
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
- A. Apply a condom catheter
- B. Assess for bladder distention
- C. Obtain a urine specimen for culture
- D. Teach the client Kegel exercises
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.