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A client had a radical mastectomy for cancer in her right breast.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
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A client has a history of oliguria, hypertension, and peripheral edema.
- A. Which nutrient should be restricted in a client with oliguria, hypertension, and peripheral edema (BUN 25, K+ 0 mEq/L)?
- B. Protein.
- C. Fats.
- D. Carbohydrates.
- E. Magnesium.
Correct Answer: A
Rationale: Oliguria, hypertension, and edema suggest renal impairment, where protein restriction reduces metabolic waste (e.g., urea nitrogen) that the kidneys cannot excrete. Fats and carbohydrates are encouraged, and magnesium restriction is not indicated.
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about hurting myself.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to
- A. achieve harmony
- B. maintain a balance of energy
- C. respect life
- D. restore yin and yang
Correct Answer: D
Rationale: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.
A 23-year-old woman in active labor.
The nurse observes the fetal heart monitor for a 23-year-old woman in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is
- A. a slowing early in the contraction, and is usually a normal finding.
- B. a slowing early in the contraction, and is usually an abnormal finding.
- C. a slowing at the peak of the contraction, and is usually a normal finding.
- D. a slowing at the peak of the contraction, and is usually an abnormal finding.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-occurs in response to compression of fetal head, uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress (2) does not indicate fetal distress (3) slowing is early in the contraction (4) slowing is early in uterine contraction and is not abnormal
A client with a diagnosis of a ruptured lumbar disc.
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
- A. Sensation loss in an upper extremity.
- B. Clonic jerks in the affected foot.
- C. Paresthesia in the affected leg.
- D. Chorea in the upper and lower extremities.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain