Nokea
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.
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The client is to take nothing by mouth after 4 a.m. The nurse recognizes that the client has deficient knowledge when he states that he:
- A. Ate a gelatin dessert at 3:30 a.m.
- B. Brushed his teeth at 4:00 a.m. but did not swallow.
- C. Held a cold washcloth against his lips.
- D. Smoked a cigarette at 6:00 a.m.
Correct Answer: D
Rationale: Smoking after 4 a.m. violates the nothing-by-mouth (NPO) order, as it introduces substances into the body and can affect anesthesia safety. The other actions either comply with NPO (brushing teeth without swallowing, holding a washcloth) or occurred before the cutoff (gelatin at 3:30 a.m.).
The nurse is planning care for a client who has returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for:
- A. Alteration in renal perfusion
- B. Electrolyte imbalance
- C. Ineffective coping
- D. Wound infection
Correct Answer: A
Rationale: Post-aortic aneurysm repair, assessing renal perfusion is critical, as the surgery may involve clamping the aorta, risking renal ischemia. Reduced urine output or elevated creatinine indicates renal compromise. Electrolyte imbalance, coping, and infection are secondary concerns.
The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. The nurse calls the client to follow up. The nurse should ask the client which of the following first:
- A. How are you feeling today?'
- B. Are you having shortness of breath?'
- C. Did you calibrate the scales before using them?'
- D. How much fluid did you drink during the last 24 hours?'
Correct Answer: B
Rationale: A 5-lb weight gain in 3 days and rising blood pressure suggest fluid retention. Asking about shortness of breath first assesses for pulmonary edema, a serious complication.
A 27-year-old female is admitted for elective nasal surgery for a deviated septum. Which of the following would be an important initial clue that bleeding was occurring even if the nasal drip pad remained dry and intact?
- A. Complaints of nausea.
- B. Repeated swallowing.
- C. Rapid respiratory rate.
- D. Feelings of anxiety.
Correct Answer: B
Rationale: Repeated swallowing may indicate postnasal bleeding, as blood may flow down the throat rather than out the nose, even if the nasal drip pad remains dry.
The client with rheumatoid arthritis tells the nurse, 'I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?' Which of the following responses by the nurse would be most appropriate?
- A. It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation.'
- B. Tell me more about your friend's arthritic condition. Maybe I can answer that question for you.'
- C. That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it.'
- D. Every person is different. What works for one client may not always be effective for another.'
Correct Answer: D
Rationale: Individual responses to treatments vary due to differences in disease severity, comorbidities, and side effect profiles. This response educates the client without dismissing their concerns.