Nokea
During history taking of a client admitted with newly diagnosed Hodgkin's disease, which symptom should the nurse expect the client to report?
- A. Weight gain
- B. Night sweats
- C. Severe lymph node pain
- D. Headache with minor visual changes
Correct Answer: B
Rationale: Assessment of a client with Hodgkin's disease most often reveals night sweats; enlarged, painless lymph nodes; fever; and malaise. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
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The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position?
- A. High Fowler's
- B. Trendelenburg's
- C. Lateral recumbent
- D. Reverse Trendelenburg's
Correct Answer: B
Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration.
To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.
The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock?
- A. Reflexes
- B. Pulse rate
- C. Temperature
- D. Blood pressure
Correct Answer: A
Rationale: Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?
- A. Identify mitral valve prolapse.
- B. Identify cardiac dysrhythmias.
- C. Rule out the possibility of pneumonia.
- D. Assess for early signs of heart failure (HF).
Correct Answer: D
Rationale: Fluid volume during pregnancy peaks between 18 and 32 weeks' gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.