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A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?
- A. Maintain the prescribed fluid restriction.
- B. Withhold the next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Assess for increasing fluid volume overload.
Correct Answer: A
Rationale: Maintaining fluid restriction is key in SIADH to prevent further sodium dilution, supporting the patient's improving sodium levels.
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Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.
The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient's pain?
- A. Activity level of bowel sounds.
- B. Level and amount of physical activity.
- C. Eating patterns of dietary intake.
- D. Color and consistency of feces.
Correct Answer: C
Rationale: Eating patterns identify foods that exacerbate pancreatitis pain, guiding dietary modifications.
An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.
A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?
- A. 100 mL/hr
- B. 125 mL/hr
- C. 150 mL/hr
- D. 175 mL/hr
Correct Answer: B
Rationale: Dividing 1000 mL by 8 hours yields 125 mL/hr, the correct infusion rate.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension signify a severe ABO incompatibility reaction, necessitating urgent reporting to prevent life-threatening complications such as renal failure or disseminated intravascular coagulation.