Nokea
A woman with a history of a left radical mastectomy is being admitted for abdominal surgery. The nurse should:
- A. Take the blood pressure only in the unaffected arm.
- B. Start an I.V. line in the affected arm.
- C. Encourage a dependent position of the affected arm.
- D. Allow blood draws in the affected arm.
Correct Answer: A
Rationale: Due to lymphedema risk post-mastectomy, blood pressure, I.V. lines, and blood draws should be avoided in the affected arm.
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The nurse is caring for a client who has just undergone a tonsillectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage frequent swallowing.
- B. Monitor for excessive swallowing.
- C. Offer ice chips immediately.
- D. Keep the head of the bed flat.
Correct Answer: B
Rationale: Monitoring for excessive swallowing is critical post-tonsillectomy, as it may indicate bleeding from the surgical site.
Which of the following should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?
- A. Cognitive and behavioral strategies.
- B. Issue avoidance and denial of problems.
- C. Rest and sleep.
- D. Withdrawal from role expectations and role relationships.
Correct Answer: A
Rationale: Cognitive and behavioral strategies, such as relaxation techniques, help clients manage anxiety effectively.
A client with a history of renal calculi is prescribed allopurinol (Zyloprim). The nurse should instruct the client to:
- A. Increase fluid intake.
- B. Avoid dairy products.
- C. Take the medication with meals.
- D. Stop the medication if pain resolves.
Correct Answer: A
Rationale: Increased fluid intake prevents stone formation while taking allopurinol for uric acid stones.
A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's physician?
- A. Vomiting after lunch.
- B. Difficulty in recalling the day of the week.
- C. Blood pressure of 102/62 mm Hg.
- D. Incontinence of urine and difficulty voiding.
Correct Answer: B
Rationale: Difficulty recalling the day of the week suggests neurological impairment, which is critical to report in a child with a brain tumor, as it may indicate tumor progression or increased intracranial pressure.
A client with a diagnosis of tuberculosis is prescribed isoniazid (INH). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild fatigue.
- B. Yellowing of the skin.
- C. Sore throat.
- D. Nausea.
Correct Answer: B
Rationale: Yellowing of the skin indicates potential hepatotoxicity, a serious side effect of isoniazid, requiring immediate reporting.