Nokea
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.
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A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
- A. Decreased serum calcium level
- B. Increased potassium level
- C. Decreased white blood cell count
- D. Increased serum albumin level
Correct Answer: A
Rationale: The correct answer is A: Decreased serum calcium level. In fat embolism syndrome (FES), fat droplets enter the bloodstream and can affect various organs. One of the common complications is hypocalcemia due to the binding of calcium to the fatty acids, leading to decreased serum calcium levels. This can result in symptoms such as confusion, tetany, and seizures. The other choices are incorrect because: B: Increased potassium level is not typically associated with FES. C: Decreased white blood cell count is not a common finding in FES. D: Increased serum albumin level is not related to FES.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Avoid reading for 1 week.
- C. Limit eye movements for 1 week.
- D. Do not bend forward at the waist for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This is important to prevent increased intraocular pressure that could lead to complications post cataract surgery. Lifting heavy objects can strain the eye and potentially disrupt the healing process.
B: Avoid reading for 1 week is incorrect as reading does not significantly impact intraocular pressure or the healing process post cataract surgery.
C: Limit eye movements for 1 week is incorrect as normal eye movements do not typically pose a risk to the surgical site after cataract extraction.
D: Do not bend forward at the waist for 1 week is incorrect as bending at the waist does not directly affect intraocular pressure or the healing of the eye after cataract surgery.
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 reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Administer nitroglycerin
- C. Place the client in a prone position
- D. Assess the client's blood pressure
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (C) is not appropriate for assessing chest pain. Assessing blood pressure (D) is important but not the initial priority when suspecting myocardial infarction.
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.