Nokea
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
- A. Skin changes
- B. Hypertension
- C. Diarrhea
- D. Increased white blood cell count
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (B), diarrhea (C), and increased white blood cell count (D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
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A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit. Which of the following findings indicate the client is most likely experiencing deep vein thrombosis (DVT)?
- A. Unilateral right lower extremity swelling and warmth below the knee
- B. Pain level as 2 on a scale of 0 to 10
- C. Ambulating in hallway with assistance
- D. Not wearing sequential compression devices
Correct Answer: A
Rationale: The correct answer is A. Unilateral right lower extremity swelling and warmth below the knee are classic signs of deep vein thrombosis (DVT). The swelling occurs due to blood clot formation, leading to impaired venous return and warmth due to inflammation. Choice B is incorrect because pain level alone is not a specific indicator of DVT. Choice C is incorrect as ambulating with assistance does not directly relate to DVT. Choice D is incorrect as not wearing sequential compression devices does not definitively indicate DVT.
A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the clients risk for falls?
- A. The client had cataract surgery 1 day ago.
- B. The client uses a hearing aid.
- C. The client has a history of hypertension.
- D. The client has a history of constipation.
Correct Answer: A
Rationale: Correct Answer: A. The client had cataract surgery 1 day ago.
Rationale: Cataract surgery can lead to temporary visual impairment, affecting depth perception and balance, increasing fall risk.
Summary:
B: Using a hearing aid does not directly increase fall risk.
C: History of hypertension does not directly increase fall risk for falls.
D: History of constipation does not directly increase fall risk for falls.
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. The client has decreased mucus production.
- B. The clients daily peak expiratory flow (PEF) measures 85% above personal best.
- C. The client has a respiratory rate of 24/min.
- D. The client reports no nighttime coughing.
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma. Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness. Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?
- A. BUN 24 mg/dL
- B. Blood glucose 95 mg/dL
- C. Platelets 250
- D. 000/mm³
- E. Hemoglobin 14 g/Dl
Correct Answer: A
Rationale: The correct answer is A: BUN 24 mg/dL. Cyclosporine, an immunosuppressant medication, can cause nephrotoxicity as an adverse effect. An elevated BUN level indicates impaired kidney function, which can be a consequence of cyclosporine therapy. Blood glucose level (choice B) and platelet count (choice C) are not typically affected by cyclosporine. Hemoglobin level (choice E) is not directly related to cyclosporine therapy. Therefore, the nurse should be vigilant for signs of nephrotoxicity by monitoring the client's BUN level.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to efficiently pump blood to the lungs for oxygenation, leading to fluid backup in the systemic circulation. This results in fluid retention, particularly in the abdomen, causing increased abdominal girth. Crackles in the lungs (choice A) are indicative of left-sided heart failure. Pink frothy sputum (choice C) is a sign of pulmonary edema, which is a manifestation of left-sided heart failure. Hypertension (choice D) is not typically associated with right-sided heart failure.