Nokea
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will avoid drinking liquids with meals.
- C. I will eat spicy foods to improve appetite.
- D. I will drink hot liquids to settle my stomach.
Correct Answer: A
Rationale: The correct answer is A: "I will eat food that are served at room temperature." This is correct because consuming foods at room temperature helps reduce nausea associated with chemotherapy and radiation. Cold foods can worsen nausea, while hot foods can trigger vomiting. Avoiding extreme temperatures can help alleviate nausea.
Choice B is incorrect because avoiding liquids with meals can lead to dehydration and worsen nausea. Choice C is incorrect because spicy foods can exacerbate nausea rather than improve appetite. Choice D is incorrect because drinking hot liquids can aggravate nausea.
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A nurse is caring for a client who has heart failure and a new prescription for furosemide. For which of the following adverse effects should the nurse monitor?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypertension
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. This can lead to hypokalemia, which can be dangerous in a client with heart failure as it can worsen cardiac function and lead to arrhythmias. The nurse should monitor the client's potassium levels regularly to prevent this adverse effect.
Summary of other choices:
B: Hyperkalemia - Furosemide does not typically cause hyperkalemia.
C: Hypernatremia - Furosemide is a diuretic that can lead to sodium loss, not hypernatremia.
D: Hypertension - Furosemide is actually used to treat hypertension, so it is not an adverse effect of the medication in this scenario.
A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
- A. Paraplegia
- B. Tetraplegia
- C. Quadriplegia
- D. Hemiplegia
Correct Answer: A
Rationale: The correct answer is A: Paraplegia. Damage at the T2-T3 vertebrae level affects the lower part of the body, resulting in paralysis of the legs and potentially part of the trunk (paraplegia). This injury does not affect the arms or hands, ruling out tetraplegia (B) and quadriplegia (C). Hemiplegia (D) refers to paralysis on one side of the body only, which is not the case here. Other choices are not applicable.
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
- A. Poor
- B. Favorable
- C. Uncertain
- D. Excellent
Correct Answer: A
Rationale: The correct answer is A: Poor. In stage IV ovarian cancer, the cancer has spread beyond the ovaries to distant organs, resulting in a poor prognosis. The aggressive treatments may help manage symptoms and prolong survival but the overall prognosis remains poor due to the advanced stage of the cancer. Choice B (Favorable) is incorrect because stage IV ovarian cancer has a poor prognosis. Choice C (Uncertain) is incorrect as the prognosis for stage IV ovarian cancer is generally known to be poor. Choice D (Excellent) is incorrect as stage IV ovarian cancer is not associated with an excellent prognosis due to its advanced stage.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. Skin grafting will be done to replace damaged tissue.
- B. Large incisions will be made in the eschar to improve circulation.
- C. This is a procedure to remove dead tissue from the burn area.
- D. Escharotomy is the removal of the burned area and will not improve circulation.
Correct Answer: B
Rationale: The correct answer is B: Large incisions will be made in the eschar to improve circulation. Escharotomy involves making incisions through the eschar (dead tissue) to relieve constriction and improve circulation in the burned area. By performing escharotomy, blood flow is restored, reducing the risk of compartment syndrome and tissue necrosis.
Choice A is incorrect because skin grafting is a separate procedure done to replace damaged tissue, not part of an escharotomy. Choice C is incorrect as it describes debridement, not escharotomy. Choice D is incorrect since escharotomy aims to improve circulation rather than remove the burned area entirely.