Nokea
A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care?
- A. Altered urinary elimination
- B. Impaired gas exchange
- C. Fluid volume excess
- D. Decreased cardiac output
Correct Answer: C
Rationale: Hyponatremia (low sodium level) is often associated with fluid volume excess in clients with lung carcinoma.
You may also like to solve these questions
Which assessment indicates that the parent of a 7-year-old is following the prescribed treatment for congestive heart failure (CHF)?
- A. HR of 56 beats per minute
- B. Elevated red blood cell count
- C. 50th percentile height and weight for age
- D. Urine output of 0.5 cc/kg/hr
Correct Answer: C
Rationale: Normal growth (50th percentile) indicates good nutrition and overall health, suggesting that CHF is well controlled.
Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement?
- A. Patch one eye and then the other every few hours
- B. Encourage bedrest until the diplopia is resolved
- C. Instruct the client to limit intake of oral fluids
- D. Administer artificial tear drops to both eyes
Correct Answer: A
Rationale: Patching each eye helps alleviate double vision caused by MS-related vision impairment.
Congenital heart disease causing cyanosis without respiratory distress include EXCEPT
- A. tricuspid atresia
- B. aortic stenosis
- C. Ebstein anomaly
- D. pulmonary atresia
Correct Answer: B
Rationale: Tricuspid atresia, Ebstein anomaly, and pulmonary atresia can cause cyanosis without respiratory distress, while aortic stenosis typically does not.
When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
- A. A reduced white blood cell count
- B. A decreased platelet count
- C. Shallow respirations
- D. Tachypnea
Correct Answer: D
Rationale: Tachypnea is a compensatory mechanism in metabolic acidosis to help expel excess carbon dioxide and correct the acid-base imbalance.
A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?
- A. Thrombus formation
- B. Infection
- C. Bronchospasm
- D. Heart failure
Correct Answer: A
Rationale: After a cardiac catheterization, the nurse must monitor for thrombus formation as it is a common complication in the first 24 hours.