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In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
- A. Enlarged, painless lymph nodes.
- B. Headache.
- C. Hyperplasia of the gums.
- D. Unintentional weight loss.
Correct Answer: A
Rationale: Early-stage CLL is often asymptomatic but may present with enlarged, painless lymph nodes due to lymphocyte accumulation. Headache, gum hyperplasia, and weight loss are not typical early findings.
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Which of the following nursing interventions would be most helpful in making the respiratory effort of a client with metastatic lung cancer more efficient?
- A. Teaching the client diaphragmatic breathing techniques.
- B. Administering cough suppressants as ordered.
- C. Teaching and encouraging pursed-lip breathing.
- D. Placing the client in a low semi-Fowler's position.
Correct Answer: C
Rationale: Pursed-lip breathing helps prolong exhalation, reducing air trapping and improving respiratory efficiency in clients with metastatic lung cancer.
The nurse is caring for a client prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply
- A. Diphenhydramine
- B. Acetaminophen
- C. 0.9% saline bolus
- D. Regular insulin
- E. Sodium bicarbonate
Correct Answer: A,B,C
Rationale: Amphotericin B infusions can cause infusion reactions and nephrotoxicity. Choice A (diphenhydramine) and Choice B (acetaminophen) are given to prevent infusion reactions like fever and chills. Choice C (0.9% saline bolus) helps protect the kidneys by ensuring adequate hydration. Choice D (insulin) and Choice E (sodium bicarbonate) are not routinely used.
After the nurse teaches a client about wearing a back brace after a spinal fusion, which of the following client statements indicates effective teaching?
- A. I will apply lotion before putting on the brace.'
- B. I will be sure to pad the area around my iliac crest.'
- C. I will use baby powder under the brace to absorb perspiration.'
- D. I will wear a thin cotton undershirt under the brace.'
Correct Answer: D
Rationale: A thin cotton undershirt prevents skin irritation while allowing the brace to fit properly.
Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
- A. Call for both clients' blood transfusions at the same time.
- B. Ask the nurse to verify the compatibility of both units at the same time.
- C. Call for and hang the first client's blood transfusion.
- D. Ask another nurse to call for and hang the blood for the second client.
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.