Nokea
A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
- A. Impaired skin integrity
- B. Fluid volume excess
- C. Acute pain and anxiety
- D. Peripheral neurovascular dysfunction
Correct Answer: A
Rationale: Vesicants can cause severe tissue damage if they extravasate, leading to impaired skin integrity.
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Peak expiratory flow rate:
- A. Is a sensitive parameter to assess improvement to therapy in acute bronchial asthma
- B. Measures small airway resistance
- C. Is more related to height rather than age
- D. Less than 50% of normal is an indication for aminophylline therapy in acute asthma
Correct Answer: A
Rationale: Peak expiratory flow rate is a useful tool to monitor response to asthma therapy, particularly in acute exacerbations.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client’s teaching?
- A. The best way to lose weight is a high-protein, low-carbohydrate diet.
- B. You should balance weight loss with consuming the necessary nutrients.
- C. A nutritionist will provide you with information about your new diet.
- D. If you exercise more frequently, you won’t need to change your diet.
Correct Answer: B
Rationale: Balancing weight loss with proper nutrient intake is essential for clients with diabetes and high BMI to reduce the risk of coronary artery disease.
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
- A. Belching
- B. Amber urine
- C. Yellow sclera
- D. Flatulence
Correct Answer: C
Rationale: Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.
A 16-year-old being treated for hypertension has laboratory values of: Hemoglobin: 16 g/dL Hematocrit: 43% Sodium: 139 mEq/L Potassium: 4.4 mEq/L Total cholesterol: 220 mg/dL Which drug does the nurse suspect the patient takes based on the total cholesterol?
- A. Beta blockers
- B. Calcium channel blockers
- C. ACE inhibitors
- D. Diuretics
Correct Answer: A
Rationale: Beta blockers are used with caution in patients with hyperlipidemia, hyperglycemia, and impotence.
In the treatment of asthma, inhaled corticosteroids:
- A. Relieve acute symptoms
- B. Prevent long-term symptoms
- C. Cause airway constriction
- D. Are contraindicated in pregnancy
Correct Answer: B
Rationale: Inhaled corticosteroids are used in asthma management to prevent inflammation and control long-term symptoms, though they do not relieve acute attacks.