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A nurse is teaching a 62-year-old female who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs:
- A. If all cancer cells are not removed.
- B. In older women.
- C. At any time after surgery or not at all.
- D. Only with radical mastectomy.
Correct Answer: C
Rationale: Lymphedema can occur at any time after mastectomy with lymph node dissection due to disrupted lymphatic drainage, or it may never occur.
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The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create
A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these findings as indicating which of the following?
- A. Expected common adverse effects.
- B. Hypersensitivity reaction.
- C. Possible habituating effect.
- D. Hemorrhage from gastrointestinal irritation.
Correct Answer: B
Rationale: These vital signs suggest a hypersensitivity reaction, a serious adverse effect of carisoprodol.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
- A. Showing the location of the obstruction and the collateral circulation
- B. Scanning the affected extremity and identifying the areas of volume changes
- C. Using ultrasound to estimate the velocity change in the blood vessels
- D. Determining how long the client can walk
Correct Answer: A
Rationale: An arteriogram involves injecting contrast dye to visualize arteries, revealing the location of obstructions and collateral circulation in occlusive arterial disease. It is a direct imaging method, unlike ultrasound (velocity changes) or volume scans, and walking duration is not assessed.
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it exiting from her total hip incision. She asks the nurse, 'Is this supposed to be there?' Which of the following represents the nurse's best response?
- A. œThe drainage is blood and fluid that must be drained out for healing.'
- B. œDon't worry about it. I will explain it when you are more awake.'
- C. œThis blood is being kept sterile and will be given back to you.'
- D. œI will give you something to make you sleep so you will not worry.'
Correct Answer: A
Rationale: Explaining that the drain removes blood and fluid for healing reassures the client and accurately describes the purpose of the drain in a total hip incision.