Nokea
A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, 'How much longer will it be?' Which response by the nurse is most appropriate?
- A. This must be a terrible situation for you.
- B. I don't know. I'll call the doctor.
- C. I cannot say exactly. What are your concerns at this time?
- D. Don't worry, it will be very soon.
Correct Answer: C
Rationale: This response acknowledges the family's concern, provides an honest answer, and opens the conversation to address their specific worries, promoting therapeutic communication.
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The client is having a cardiac catheterization. During the procedure, the client tells the nurse, 'I'm feeling really hot.' Which response would be best?
- A. You are having an allergic reaction. I will get an order for Benadryl.
- B. That feeling of warmth is normal when the dye is injected.
- C. That feeling of warmth indicates that the clots in the coronary vessels are dissolving.
- D. I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.
Correct Answer: B
Rationale: A warm sensation is a normal response to the injection of contrast dye during cardiac catheterization.
The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?
- A. Diabetes
- B. Prinzmetal's angina
- C. Cancer
- D. Cluster headaches
Correct Answer: B
Rationale: Prinzmetal's angina is a contraindication for sumatriptan due to the risk of coronary vasospasm, and this should be reported to the doctor.
A 32-year-old male client has just undergone a liver biopsy and is released to the post-op floor for observation. The nurse should have the client lie in what position?
- A. semi-Fowler's
- B. on his right side
- C. supine
- D. on his left side
Correct Answer: B
Rationale: Lying on the right side applies pressure to the liver biopsy site, reducing bleeding risk.
When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:
- A. Cherry-red urine that gradually becomes clearer
- B. Orange-tinged urine containing particles of calculi
- C. Dark red urine that becomes cloudy in appearance
- D. Dark, smoky-colored urine with high specific gravity
Correct Answer: A
Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months, so a 7-pound newborn would weigh approximately 14 pounds.