Nokea
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
- A. Patient complains of severe fatigue.
- B. Patient voids every hour during the day.
- C. Patient takes only 50% of meals and refuses snacks.
- D. Patient has crackles up to the midline posterior chest.
Correct Answer: D
Rationale: High-rate fluids (175 mL/hr) plus chemo in an older colorectal patient can swamp the heart crackles to midline yell heart failure, trumping fatigue , peeing , or poor eating . Nurses in oncology flag this lungs drowning need stat help, a fluid overload crisis.
You may also like to solve these questions
The Barker hypothesis describes the relationship between birth weight and the development of diseases. Question: Which relationship is correct?
- A. High birth weight is associated with a reduced risk of obesity, diabetes and/or cardiovascular disease at a later age
- B. High birth weight is associated with an increased risk of obesity, diabetes and/or cardiovascular disease at a later age
- C. Low birth weight is associated with a reduced risk of obesity, diabetes and/or cardiovascular disease at a later age
- D. Low birth weight is associated with an increased risk of obesity, diabetes and/or cardiovascular disease at a later age
Correct Answer: D
Rationale: Barker's call low birth weight scars metabolism, upping later obesity, diabetes, heart woes. High weight leans risky too, but low's the proven chronic link nurses track this fetal echo.
The nurse is caring for a client with mitral regurgitation. Which of the following would the nurse anticipate the client to develop if left untreated?
- A. Left-sided heart failure
- B. Right-sided heart failure
- C. Renal failure
- D. Myocardial ischemia
Correct Answer: A
Rationale: Mitral regurgitation backflows blood into the left atrium, hiking pressure and volume untreated, it overburdens the left ventricle, leading to left-sided heart failure. Pulmonary congestion follows, with dyspnea and edema, a direct consequence of this valve flaw. Right-sided failure stems from downstream effects or separate causes, not primary here. Renal failure or ischemia might complicate advanced disease, but left-sided failure's progression is the immediate risk, rooted in mitral dysfunction's mechanics. Nurses anticipate this, monitoring for early signs like crackles, ensuring timely intervention to halt this predictable cardiac cascade.
A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns
- B. Knowledge Deficit related to disease process and diagnostic procedure
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea
- D. Anxiety related to unknown outcomes and perceived threat to body integrity
Correct Answer: D
Rationale: The patient's anger and threat to leave during colonoscopy teaching signal emotional distress overriding physical symptoms. Anxiety stemming from uncertain outcomes and perceived bodily threat fits, as colorectal cancer risk tied to polyps and family history heightens fear, blocking education uptake. Diarrhea/constipation reflects symptoms but isn't immediately urgent with scant bleeding. Knowledge deficit exists but is secondary fear drives the refusal, not just ignorance. Fluid volume risk is plausible with bleeding, yet no data suggests acute loss; stability allows focus on emotions. Addressing anxiety first calms the patient, enabling teaching and care, a priority in this tense encounter where psychological barriers could delay critical colorectal screening and intervention.
Which feature is not suspicious for allopurinol-induced SCAR?
- A. Generalised itch within 24 - 48 hours
- B. Sore throat
- C. Transaminitis
- D. Conjunctivitis
Correct Answer: A
Rationale: SCAR sore throat, liver jump, eye burn, fever scream; itch alone's mild, not dire. Nurses sift this chronic rash red flag.
What is the most influential source of self-efficacy?
- A. Mastery
- B. Affective states
- C. Verbal persuasion
- D. Vicarious experience
Correct Answer: A
Rationale: Self-efficacy's backbone is mastery past wins breed belief, a nurse's gold for chronic self-care push. Watching others, pep talks, or mood sway less; doing it trumps all, a confidence anchor in illness battles.