Nokea
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
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A nurse teaches a client with breast cancer about chemotherapy side effects. What statement indicates understanding?
- A. I'll call my doctor if I notice any unusual menstrual bleeding.
- B. I'll stop chemotherapy if I feel tired.
- C. Hair loss is always permanent.
- D. I don't need any follow-up tests after treatment.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the importance of monitoring for potential side effects like unusual menstrual bleeding, which can be a serious complication of chemotherapy. This statement reflects proactive involvement in self-care and prompt communication with healthcare providers. Choices B, C, and D are incorrect because stopping chemotherapy without medical guidance can be harmful, hair loss may not always be permanent, and follow-up tests are essential for monitoring treatment effectiveness and potential complications.
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
- A. History of breast cancer
- B. History of hypertension
- C. History of diabetes
- D. History of osteoarthritis
Correct Answer: A
Rationale: The correct answer is A: History of breast cancer. Menopausal hormone therapy (HT) is contraindicated in women with a history of breast cancer due to the potential risk of hormone-dependent cancer recurrence. Hormones can stimulate the growth of estrogen-sensitive breast cancer cells, increasing the risk of cancer recurrence. Therefore, it is crucial for the nurse to inform the client with a history of breast cancer that HT is not recommended. Choices B, C, and D are not directly contraindications for HT in menopausal clients, as long as these conditions are well-controlled and monitored.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility on the affected side.
- C. Increase independence in activities of daily living.
- D. Prevent falls during rehabilitation.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. Communication is a key aspect affected by left hemispheric CVA, which can lead to aphasia or difficulty in speaking and understanding language. By prioritizing communication goals, the nurse can enhance the client's quality of life, facilitate social interactions, and improve overall rehabilitation outcomes. Increasing mobility (B) and independence in activities of daily living (C) are important but may not directly address the communication deficits. Preventing falls (D) is also crucial but not specific to the client's primary deficit.
A nurse is caring for a postoperative client. Which procedure places the client at highest risk for DVT?
- A. Appendectomy
- B. Hip arthroplasty
- C. Cholecystectomy
- D. Tonsillectomy
Correct Answer: B
Rationale: The correct answer is B: Hip arthroplasty. This procedure involves prolonged immobility, causing blood stasis and increasing the risk of deep vein thrombosis (DVT). The reduced blood flow in the legs can lead to clot formation. Appendectomy (A), cholecystectomy (C), and tonsillectomy (D) are not typically associated with prolonged immobility like hip arthroplasty, thus lower DVT risk.
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.