Nokea
A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
- A. Vision changes
- B. Headache
- C. Hearing loss
- D. Anorexia
Correct Answer: A
Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.
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A patient with a new diagnosis of lung cancer decides to have radiation therapy. Which of the ff. expectations of this treatment is most appropriate?
- A. Complete cure of the cancer
- B. Prevention of the need for oxygen
- C. Increased comfort
- D. Prevention of cancer spread
Correct Answer: C
Rationale: The correct answer is C: Increased comfort. Radiation therapy for lung cancer aims to alleviate symptoms, reduce pain, and improve quality of life. It is not typically used as a curative treatment like surgery or chemotherapy (A). It does not prevent the need for oxygen (B), as lung cancer can still affect lung function. While radiation therapy may help control the growth of cancer cells, it is not always effective in preventing cancer spread (D). Therefore, the most appropriate expectation of radiation therapy for lung cancer is increased comfort for the patient.
A nurse is discharging a client from the hospital. When should discharge planning be initiated?
- A. At the time of discharge from an acute health care setting
- B. At the time of admission to an acute health care setting
- C. Before admission to an acute health care setting
- D. When the client is at home after acute care
Correct Answer: B
Rationale: Rationale:
1. Discharge planning should start at admission to ensure comprehensive preparation.
2. Early planning allows for assessment of needs and coordination of resources.
3. It promotes continuity of care and reduces risks of readmission.
4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.
When the nurse is reviewing a patient’s daily laboratory test results, which of the ff. electrolyte imbalances should the nurse recognize as predisposing the patient to digoxin toxicity?
- A. Hypokalemia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: A
Rationale: Step-by-step rationale:
1. Digoxin toxicity can be potentiated by hypokalemia due to the risk of enhanced cardiac toxicity.
2. Hypokalemia can lead to increased sensitivity of cardiac cells to digoxin.
3. Low potassium levels can disrupt the sodium-potassium ATPase pump, enhancing digoxin's effects.
4. The nurse should recognize hypokalemia as a predisposing factor for digoxin toxicity.
Summary:
A: Hypokalemia is the correct answer as it enhances digoxin toxicity by affecting cardiac function.
B: Hyponatremia does not directly predispose to digoxin toxicity.
C: Hyperkalemia is not a predisposing factor and can actually counteract digoxin's effects.
D: Hypernatremia is not directly related to digoxin toxicity.
A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
- A. Assist the patient to walk in the room with crutches.
- B. Obtain a walker for the patient.
- C. Consult physical therapy.
- D. Administer pain medication.
Correct Answer: D
Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery.
Explanation for other choices:
A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed.
B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain.
C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.
When caring for a client, whose being treated for hyperthyroidism, it’s important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client’s periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.