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A nurse is performing discharge teaching for a client who was recently diagnosed with heart failure. Which of the following should be included in the client and family teaching?
- A. Low sodium diet
- B. Weekly weights
- C. Symptoms to report to the provider
- D. Fluid restriction
Correct Answer: A
Rationale: Heart failure management hinges on education to prevent exacerbations. A low sodium diet reduces fluid retention, easing cardiac workload crucial teaching for clients and families to grasp, as salt drives edema and hypertension, common pitfalls in heart failure. Weekly weights track fluid shifts daily is ideal, but weekly still aids while reporting symptoms like dyspnea flags worsening. Medication teaching ensures adherence, and fluid restriction may apply, but sodium's broader impact makes it foundational. Focusing on diet empowers lifestyle change, tackling a root cause over monitoring or restrictions alone, aligning with nursing's role in empowering self-care to stabilize this chronic condition long-term.
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A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?
- A. The cancer involves only the cervix.
- B. The cancer cells look like normal cells.
- C. Further testing is needed to determine the spread of the cancer.
- D. It is difficult to determine the original site of the cervical cancer.
Correct Answer: A
Rationale: Tis, N0, M0 means carcinoma in situ cancer's stuck to the cervix's surface, no invasion (T0), no lymph nodes (N0), no metastases (M0). It's early, contained. B's wrong grading, not staging, covers cell look (differentiation). C's off no spread's confirmed already. D's nonsense the cervix is the origin. Nurses break this down in oncology to ease fears only the cervix' signals a shot at cure with local treatment, not systemic chaos yet.
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?
- A. Have the patient eat large meals when nausea is not present.
- B. Offer dry crackers and carbonated fluids during chemotherapy.
- C. Administer prescribed antiemetics 1 hour before the treatments.
- D. Give the patient a glass of a citrus fruit beverage during treatments.
Correct Answer: C
Rationale: Chemo vomiting's a beast pre-dosing antiemetics (e.g., ondansetron) an hour before blocks the gut-brain puke loop, the gold standard. Big meals overload; crackers and soda or citrus during treatment spark nausea acidity and fizz don't help. Nurses in oncology time this right prevention trumps mopping up, keeping patients steady.
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
- A. Give the patient the prescribed PRN opioid.
- B. Assess for sensation and strength in the legs.
- C. Notify the health care provider about the symptoms.
- D. Teach the patient how to use relaxation to reduce pain.
Correct Answer: B
Rationale: Stage IV lung cancer plus back pain flags spinal cord compression leg checks for numbness or weakness come first; paralysis kills fast. Opioids , calls , or relaxation follow. Nurses in oncology prioritize this neuro's the lifeline, catching mets' chaos early.
The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical-surgical unit. Which client should the nurse see first?
- A. A client with pain that is two days post-operative from a prostatectomy
- B. A client ready for discharge education after treatment of an acute kidney injury
- C. A client with hypertension with a blood pressure of 172/92 mm Hg
- D. A client with a history of asthma complaining of increased dyspnea
Correct Answer: D
Rationale: Asthma's increased dyspnea flags airway risk ABCs prioritize breathing, as bronchospasm could crash fast, needing nebulizers or oxygen. Post-op pain's manageable, discharge education waits, hypertension's high but stable. Nurses hit dyspnea first, ensuring airflow, a life-first call in this shift-start triage.
Which of the following patients would probably not benefit from a >5-10% weight loss?
- A. A 28-year-old female with BMI 37 kg/m² and oligomenorrhea but planning for fertility in the future
- B. A 40-year-old man with BMI 26 kg/m², who has a strong family history of diabetes, recently diagnosed with prediabetes
- C. A 21-year-old man with BMI 42 kg/m² with no known medical problems and a family history of T2DM
- D. A 70-year-old female, BMI 26 kg/m², with well-controlled T2DM on two oral anti-diabetic medications and osteoporosis
Correct Answer: D
Rationale: A 5-10% weight loss benefits most with obesity-related conditions improving fertility (BMI 37), prediabetes (BMI 26), or T2DM risk (BMI 42). The 70-year-old with BMI 26, well-controlled T2DM, and osteoporosis may not benefit significantly; weight loss could worsen bone density, and her diabetes is managed, reducing urgency. Her age and comorbidities shift focus to stability, not weight reduction, guiding physicians in chronic care prioritization.