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A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?
- A. Check the results of the client's most recent CBC
- B. Administer a blood transfusion
- C. Offer the client a stimulant medication
- D. Advise the client to reduce physical activity
Correct Answer: A
Rationale: The correct answer is A: Check the results of the client's most recent CBC. Fatigue is a common side effect of cisplatin, which can cause bone marrow suppression leading to anemia. Checking the CBC will help determine if the client is experiencing anemia, which can be managed with appropriate interventions. Administering a blood transfusion (B) should not be done without confirming the need through lab results. Offering a stimulant medication (C) may mask the underlying cause of fatigue. Advising the client to reduce physical activity (D) may not address the root cause of the fatigue.
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A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make?
- A. I will need to apply electrodes to your chest and extremities.
- B. You may feel some discomfort during the procedure.
- C. The procedure will take about an hour.
- D. We need to monitor your heart rate continuously after the procedure.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Applying electrodes to the chest and extremities is necessary for a complete ECG recording. Electrodes are placed strategically to capture electrical activity of the heart. This statement informs the client about the procedure and ensures accurate results. Other options are incorrect because discomfort during the procedure is subjective and not guaranteed (B), an ECG typically takes only a few minutes, not an hour (C), and continuous heart rate monitoring is not required post-procedure unless indicated by the results (D).
A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice services for the client. Which of the following statements by the client indicates a correct understanding of hospice care?
- A. I should expect the hospice team to help me manage my dyspnea.
- B. I will receive chemotherapy to treat my cancer.
- C. I will be admitted to the hospital for further treatment.
- D. I will receive radiation therapy to shrink the tumor.
Correct Answer: A
Rationale: Correct Answer: A - "I should expect the hospice team to help me manage my dyspnea."
Rationale: Hospice care focuses on providing comfort and quality of life for patients with terminal illnesses, such as advanced lung cancer. Dyspnea (difficulty breathing) is a common symptom in lung cancer patients, and the hospice team is trained to provide symptom management and relief. By acknowledging the role of the hospice team in managing dyspnea, the client demonstrates an understanding of the palliative nature of hospice care.
Summary of other choices:
B: "I will receive chemotherapy to treat my cancer." - Hospice care does not aim to cure the underlying illness but rather focuses on comfort and quality of life.
C: "I will be admitted to the hospital for further treatment." - Hospice care is typically provided in the comfort of the patient's own home or a hospice facility, not in a hospital setting for further treatment.
D: "I will receive radiation therapy
A nurse is planning care for a client with a T4 spinal cord injury at risk for UTIs. What should be included?
- A. Limit fluid intake.
- B. Encourage fluid intake at and between meals.
- C. Restrict intake of acidic foods.
- D. Use an indwelling catheter continuously.
Correct Answer: B
Rationale: The correct answer is B: Encourage fluid intake at and between meals. This is because increasing fluid intake helps to flush out bacteria from the urinary tract, reducing the risk of UTIs. Limiting fluid intake (choice A) can lead to concentrated urine, making it easier for bacteria to multiply. Restricting acidic foods (choice C) does not directly impact the risk of UTIs. Using an indwelling catheter continuously (choice D) actually increases the risk of UTIs due to the constant presence of a foreign body in the urinary tract. Encouraging fluid intake at and between meals is the most effective way to prevent UTIs in clients with spinal cord injuries.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
- A. Take the medication early in the day.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication only when blood pressure is high.
Correct Answer: A
Rationale: The correct answer is A: Take the medication early in the day. Hydrochlorothiazide is a diuretic that increases urine production, which can cause frequent urination. Taking it early helps prevent nighttime urination, promoting better sleep. Taking it with food may reduce gastrointestinal upset. Taking it only when blood pressure is high is incorrect, as it should be taken regularly to maintain consistent blood pressure control. Bedtime dosing may lead to nocturnal diuresis and disturb sleep. The other choices are irrelevant or incorrect in the context of hydrochlorothiazide administration.